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Appendix VI RECEIVED MONITORING SYSTEM CERTIFICATION JUN 12 2018 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 of Regulations ENVIRONMENTAL F !T`I R Qn...RT��-NT This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be r r tl'for 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 Information Facility JAMAR SVC Bldg.No.: N.T.- Site 9 Site Addracc• 4075 EAST MAIN STREET City: STOCKTON Zip: 96206 Facility Contact PPrenn• JASON Contact Phone No.: (209)462-4686 Make/Model of Monitoring System. VEEDER ROOT TLS 350 Date of Testing/Servicing: 6/17/18 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: TanklD: 87 TanklD: 91 Z In-Tank Gauging Probe. Model MAG 1 Z In-Tank Gauging Probe. Model: MAG 1 Z Annular Space or Vault Sensor. Model 409 Z Annular Space or Vault Sensor. Model: SPILT/87 ® Piping Sump/Trench Sensor(s). Model: 208 Z Piping Sump/Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: PE PETRO Z Mechanical Line Leak Detector. Model: 99 LD 2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill/High-Level Sensor. Model: FLAPPER Z Tank Overfill/High-Level Sensor. Model: FLAPPER ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). TanklD: NA TanklD: NA ❑ 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. ❑ 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 lD 3-4 ❑ Dispenser Containment Sensor(s). Model. ❑ Dispenser Containment Sensor(s). Model Z Shear Valve(s). Z Shear Valve(s). Z Dispenser Containment Float(s)and Chain(s). Z Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5-6 Dispenser ID: 7-8 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Z Shear Valve(s). Z Shear Valve(s). Z Dispenser Containment Float(s)and Chain(s). Z Dispenser Containment Float(s)and Chain(s). Dispenser ID: NA Dispenser ID: NA ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: Sensor(s). Model: ❑ Shear Valve(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 form. Include information for every tank and dispenser at the facility. 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 that apply): ®System set-up ®Alarm history report Technician Name(print): FELIX RAMIREZ Signature: j/.t - Certification No.: B34976 License No: 8883072-UT 08-1740 OTTL Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 2ntl STREET GALT,CA 95632 Date of Testing/Servicing: 05-17-18 Monitoring System Certification Page 1 of 4 2/21/07