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e RECEIVED Appendix VI NOV 0 2 2017 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,Californ��de of Regulations HEALTH This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be=prepared for p� each monitoring system control panel by the technician who performs the work.A ropy of this form must be provided to the tank system i LI VT ownerloperator.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: SUPER STORES INDUSTRIES Bldg.No.: Site Address: 16888 MCKINLEY AVE. City: LATHROP CA Zip: 95330 Facility Contact Person: Kevin Contact Phone No.: ( } Make/Model of Monitoring System: VEEDER ROOT TLS-350 Date of TesfinglServicing: 10/6/2017 3. Inventory of Equipment TestedlCertified Check the appropriate boxes to indicatespecific equipment ins ectediserviced: Tank ID: NEW OIL Tank Size: Tank ID: WASTE OIL Tank Size: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 3 03 0 Annular Space or Vault Sensor. Model: 3 0 3 ® Piping Sump/Trench Sensor(s). Model: 2 0 8 ® Piping Sump!Trench Sensor(s). Model: 2 0 8 ❑ 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) Tank ID: DIE Tank Size: WEST Tank ID: DIE Tank Size: I:AS'I' ❑ !n-Tank Gauging Probe. Model; ❑ In-Tank Gauging Probe. Model; Z Annular Space or Vault Sensor. Model: 3 03 0 Annular Space or Vault Sensor. Model: 3 0 2 ® Piping Sump v Trench Sensor(s). Model: 209 ® Piping Sump I Trench Sensor(s). Model: 2 0 9 ❑ Fill Sump Sensor(s). Model ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: 99 LD 2000 ® Mechanical Line Leak Detector. Model: 99 LD 2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill 1 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 medei in Section E on Page 2). Dispenser ID: I / 2 Dispenser ID: 3 / 4 Z Dispenser Containment Sensor(s). Model: BEI-406 ❑ Dispenser Containment Sensor(s)_ Model, BE 1 - 406 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Floats)and Chain(s). Dispenser 10: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valve(s). Cl Sheat 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{ )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 inspectediserviced 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): ZANE NIMMO Signature: Certification No.: A26446 License No: 04-1676 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 2'STREET GALT,CA 95632 Date of Testing/Servicing: 10/6,+2017 Monitoring System Certification Page f of 4 2/21/07