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• • REFI ® Appendix VI OCT 13 2016 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,and CaUfpptia.Gode.cf.R eftA TH This form must be used to document testing and servicing of monitoring equipment.A separate certification or report mus M tiV I Tit each monitoring system control panel by the technician who performs the work.A copy of this form must be provided tot M ENT owner/operator.The owner/operator must submit a mpy of this forth to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: SUPER STORE Bldg.Nc.: Site Address: 16888 MCKINLEV AVE City: LATHROP Zip: 95330 Facility Contact Person: KEVIN Contact Phone No.: (209)8584384 Make/Model of Monitoring System: VEEDER ROOT TLS 350 Dale of Tasting/Servicing: 10-07-16 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicatespecific a ui ment ins ected/serviced: Tank ID: —DIESEL 1 Tank ID: DIESEL N In-Tank Gauging Probe. Model: MAG 1 N In-Tank Gauging Probe. Model: MAG 1 N Annular Space or Vault Sensor. Model: 303 N Annular Space or Vault Sensor. Model: 303 N Piping Sump/Trench Sensor(s). Model: 208 N Piping Sump/Trench Sensogs). Model: 208 ❑ Fill Sump Sensogs). Model: ❑ Fill Sump Sensors). Model: N Mechanical Line Leak Detector. Model: 99 LD 2000 N Mechanical Line Leak Detector. Model: 99 LD 2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: N Tank Overfill/High-Level Sensor. Model: FLAPPER N 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). Tank ID: WASTE OIL Tank ID: NEW OIL ❑ In-Tank Gauging Probe. Model, ❑ In-Tank Gauging Probe. Model: N Annular Space or Vault Sensor. Model: 303 N Annular Space or Vault Sensor. Model: 303 N Piping Sump/Trench Sensor(s). Model: 208 N Piping Sump/Trench Sensor(s). Model: 208 ❑ 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). DlspenserlD: 1-2 Dispenser ID: 3-4 N Dispenser Containment Sensor(s). Model: 406 N Dispenser Containment Sensods). Madel: 406 N Shear Valve(s). N Shear Valve(s). ❑ Dispenser Containment Flom(s)and Chain(s). ❑ Dispenser Containment Flaat(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Floats)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: Sensor(s). Model: ❑ Shearvalve(s). ❑Shear Valve(s). ❑ Dispenser Containment Floats)and Chain(s). ❑ Dispenser Containment Floats)and Chain(s). `If the facility contains more tanks or dispensers,copy this forth. 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): N System set-up N Alamt history report Technician Name(pent): FELIX RAMIREZ Signature: d r ` -__> Certlfcatron No.: 5273934-UT License No: 08-1740 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 2n°STREET GALT,CA 95632 Date of Testing/Servicing: 10-0746 Monitoring System Certification Page 1 of 2/21/07