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Appendix VI MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Co This This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared fo each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. JUN O A. General Information Facility Name: JAMAR SERVICE VALERO Bldg. No.: II911 80111 ue►rTA` Hwfflo Site Address: 4075 E MAIN STREET City: STOCKTON CA zip: PERMIT/Q� MCEg Facility Contact Person: JAY Contact Phone No.: (209) 462-4685 Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 5.15-2014 B. Inventory of Equipment Tested/Certified f .ran Check the appropriate boxes to Indicatespec I Ic e wp e --- Tank ID: 91 TanklD: 87 ® In -Tank Gauging Probe. Model: MAG 1 ® In -Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 409 ❑ Annular Space or Vault Sensor. Model: SPLIT ® Piping Sump / Trench Sensor(s). Model: 208 ® Piping Sump / Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: FE PETRO ® Mechanical Line Leak Detector. Model: FE PETRO ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Tank Overall / High -Level Sensor. Madel: ❑ Other (specify equipment type and model in Section E on Page 2). Tari Tank lD: ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑, Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: 1-2 Dispenser ID: 5-6 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ® Shear Velvets). ® Dispenser Containment Float(s) and Chain(s). ® Dispenser Containment Float(s) and Chain(s). Dispenser ID: 3-4 Dispenser ID: 7-8 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ® Dispenser Containment Float(s) and Chain(s). ® Shear Valve(s). ® Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: Sensor(s). Model: ❑ Shear Valve(s). 11 ❑ Dispenser Containment Float(s) and Chain(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). -if the facility contains more tanks or dispensers, copy this form. include miormanon nor every rank ano cispenser ar uie muo,y. C. Certification - I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is Information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the report; (check all char apply): ® System set-up ® Alarm history report Technician Name (print): DAVE WINKLER Signature: ��__. _-) Certification No.: 5263373 -UT License No: 08-1739 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 Testing Company Address: 416 2 STREET GALT, CA 95632 Date of Testing/Servicing: 5-15-2014 Monitoring System Certification Page 1 of 4 2/21/07 SC F -A