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6�W�: : :•BIN: Z1 • Appendix VI ! ; 217 MONITORING SYSTEM CERTIFICATION '-'" I rgLt'E"IL For Use By All Jurisdictions Within the State of California FEf�/• ""; ., Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3,Title 23,California Code of Regulatioris/Z8 This form must be used to document tasting and servicing of monitoring equipment.A separate certification or report must be prepared for each monitoring system control panel by the technician who performs the work.A copy of this farm 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 Name: JAMAR SVC Bldg.No.: Site Address: 4075 EAST MAIN STREET City: STOCKTON Zip: Facility Contact peon" JASON Contact Phone No.: (209)462.4685 Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 511/2017 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment ins ctecilserviced: Tank ID: 87 Tanli 91 ® In-Tank Gauging Probe. Model: MAGI ® In-Tank Gauging Probe. Model: MAGI ® Annular Space or Vault Sensor. Model: 409 ® Annular Space or Vault Sensor. Model: SPILT/87 ® Piping Sump/Trench Sensor(s). Madel: 208 ® Piping Sump I Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: PE PETRO ® Mechanical Line Leak Detector. Model: 99 LD 2000 ❑ Electronic Line Leak Detector. Model. ❑ Electronic Line Leak Detector. Madel. ® Tank Overfll/High-Level Sensor. Model: FLAPPER ® Tank Overfill/High-Level Sensor. Madel: FLAPPER ❑ Other(specify equipment type and model in Section E on Page 2). El Other(specify equipment type and model in Section E on Page 2). Tank lD: NA TanklD: NA D 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 I 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: 3-4 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ® Shear Velvets). ® Shear Valve(s). ® Dispenser Containment Float(s)and Chain(s). ® Dispenser Containment Float(s)and Chairi Dispenser ID: 5-6 Dispenser ID: 7-8 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Senscr(s). Model: ® Shear Valve(s). ® Shear Valve(s). J ® Dispenser Containment Floats)and Chain(s). ® 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 certity 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 verity 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: Certification No.: 834976 License No: 5273934-UT 08-1740 OTTL Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 2-STREET GALT,CA 95632 Date of Testing/Servicing. 05-01-17 Monitoring System Certification Page 1 of 4 2/21/07 WC