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6Appendix VI { IVED MONITORING SYSTEM CERTIFICATION I''�y 2u18 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 Code asR)y,,Cv !MENTAL Regulations (-)rppgTpAENT This form must be used to document testing and servicing of monitoring equipment.A separate certdication or report must be prepared few 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. A. General lnfurmation FacilityV. MANTECA LIQUOR&FOOD site Bldg.No.: Site Addreal; 680 N MAIN ST City: MANTECA CA Zi 96336 Facility Contact p� Person DEET Contact Phone No.: (209)765-2619 Make/Model of MonitoringSystem: VEEDER ROOT TLS 350 4-16.18 Y Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates ecific a ui ment ins ected/serviced: TanklD: 87 OCT Tank ID: 91 OCT N In-Tank Gauging Probe. Model: MAG 1 N In-Tank Gauging Probe. Madel: MAG 1 N Annular Space or Vault Sensor, Model: 420 N Annular Space or Vault Sensor. Model: 420 N Piping Sump/Trench Sensor(s). Model: 208 N Piping Sump/Trench Sensor(s). Model: 208 ❑ Fill Sump Sensors). Model: ❑ Fill Sump Sensors). Model: N Mechanical Line Leak Detector. Model: FXIX N Mechanical Line Leak Detector. Model: FE PETRO ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). Tank ID: DSL Tank ID: N In-Tank Gauging Probe, Model: MAG 1 ❑ In-Tank Gauging Probe. Model: N Annular Space or Vault Sensor. Model: 420 ❑ Annular Space or Vault Sensor. Model: N Piping Sump/Trench Sensor(s). Model: 208 ❑ Piping Sump/Trench Sensogs). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: N Mechanical Line Leak Detector. Model: FXIV D ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). Dispenser ID: 1.2 Dispenser ID: N Dispenser Containment Sensor(s). Model: 208 ❑ Dispenser Containment Sensor(s). Model: N Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dlspensti 3-4 Dispenser ID: N Dispenser Containment Sensors). Model: 208 ❑ Dispenser Containment Sensors). Model: N Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: Sensor(s). Model: ❑ ShearValve(s). ❑Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). -if the facility contains more tanks or dispensers,copy this torte. Include information for every tank and dispenser at the facility. C.Certification-I certify that the equipment Identified In this documentwas 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 that apply): ®System set-up N Alarm history report Technician Name(print): DAVE WINKLER Signature: Certification No.: 8883059-UT License No: 08-1739 Testing Company Name: AFFORDA-TESTPhone No. (209)744-0113 Testing Company Address: 416 2n°STREET GALT CA 95632 Date of Testing/Servicing: 4-16-18 Monitoring System Certification Page 1 of 4 2/21/07