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KECEIVED MAY 12 &/ Appendix VI ERVIRONMENTAL HEALTH PERANDSERVICES (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at httD://www.waterboards.ca.Dov.) 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, California Code of Regulations This tone must be used to document testing 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 form must be provided to the tank system owner/operator. The owner/operator must submit a copy of this forth to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: FAST AND EASY Bldg.No.: Site Address: 10878 N.HWY 99 City: STOCTON CA, Zip: 95212 Facility Contact Person: MIKE ALE Contact Phone No.: MakelModel of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 4/24/2017 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate speclitic equipment ins serviced: Tank ID: 1 premium Tank to UNLEADED X In-Tank Gauging Probe. Model:VR MAG PROB X In-Tank Gauging Probe. Model: VR MAG PROB X Annular Space or Vault Sensor. Model:VR 420 X Annular Space or Vault Sensor. Model: VR 420 X Piping Sump/Trench Sensor(s). Model:VR 208 X Piping Sump/Trench Sensor(s). Model: VR 208 Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: X Mechanical Line Leak Detector. Model:VMI LD 2000 X Mechanical Line Leak Detector. Model: RED JACKET FXIV ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify a ui mt2 a and model in Section E on Pae 2). ❑ Other(specify equipment and model in Section E on Page 2). Tank ID:2 premium#2 Tank ID: DIESEL X In-Tank Gauging Probe. Model:VR MAG PROS X In-Tank Gauging Probe. Model: VR MAG PROB X Annular Space or Vault Sensor. Model:VR 420 X Annular Space or Vault Sensor. Model: VR 420 X Piping Sump/Trench Sensor(s). Model:VR 208 X Piping Sump/Trench Sensor(s). Model: VR 208 Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: X Mechanical Line Leak Detector. Model:VMI LD 2000 X Mechanical Line Leak Detector. Model:RED JACKET FXIDV ❑ Electronic Line Leak Detector. Model: n Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment[ and model in Section E on Page 2). ❑ Other(specify equipment and model in Section E on Pae 2). Dispenser ID:1/2 Dispenser ID:718 Dispenser Containment Sensor(s). Model ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). r Shear Valve(s). X Dispenser Containment Float(s)and Chain(s).BROVO X Dispenser Containment Floats and Chains.BROVO Dispenser to:3/4 Dispenser ID: 9/10 l Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: Shear Valve(s). ❑ Shear Valve(s). X Dispenser Containment Floats and Chain(s).BROVO Dispenser Containment Floats and Chain(s). Dispenser to:5/6 DlspenserlD: Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). ❑ Shear Valve(s). X Dispense Containment Floats and Chains BROVO Dispenser Containment Floats 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'check' necessary to verity that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equip capab o gen ting such reports, I have also attached a copy of the report;(check all that apply): i System set-up Alarm story re Technician Name(print):JASON HAASE Signature: Certification No.: B40970 License.No.: 920 Testing Company Name:MID VALLEY CONSULTING Phone No.:(530) 9-9892 Testing Company Address: 1097 BRONCO DRIVE,PLUMAS LAKE,CA 95961 Date of Testing/Servicing: 4/24/2017 Monitoring System Certification Page 1 of 4 12107 1 2/21/07