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Appendix VI MONITORING SYSTEM CERTIFICATION JUN 06 2016 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 RegulatLO This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be prepafed 'RwN?*F -- each monitoring system control panel by the technician who performs the work.A copy of this form must be provided to the tent-'+terrw�. .e 1.�__ 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 lnformaton: Facility Name: ARCH RD AM PM Bldg.No.: Site Address: 4855 SOUTH HWY 99 City: Zip: Facility Contact Person: STOCKTON CA Contact Phone No.: ( ) Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 2/8/2016 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific a ui ment Ins ected/serviced: Tank ID: 87 Tank Size: Tank ID: 91 Tank Size: ® In-Tank Gauging Probe. Model: MAG 1 ® In-Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 409 ® Annular Space or Vault Sensor. Model: 409 ® Piping Sump/Trench Sensor(s). Model: 323 ® Piping Sump/Trench Sensor(s). Model: 323 ® Fill Sump Sensor(s). Model: 344 ® Fill Sump Sensor(s). Model: 323 99LD 2000 2ND NOT ® Mechanical Line Leak Detector. Model: INSTALLED ® Mechanical Line Leak Detector. Model: 99LD 2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overall/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: 89 Tank Size: Tank ID: Tank Size: ® In-Tank Gauging Probe. Model: MAG 1 ❑ In-Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 409 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump/Trench Sensor(s). Model: 323 ❑ Piping Sump/Trench Sensor(s). Model: ® Fill Sump Sensor(s). Model: 323 ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: 99LD 2000 ❑ 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 ID: 7-8 ® Dispenser Containment Sensor(s). Model: 323 ® Dispenser Containment Sensor(s). Model: 323 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Floats)and Chain(s). Dispenser ID: 3-4 Dispenser ID: 9.10 ❑ Dispenser Containment Sensor(s). Model: 323 ® Dispenser Containment Sensor(s). Model: 323 ❑ Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5-6 Dispenser ID: 11-12 ® Dispenser Containment ® Dispenser Containment Sensor(s). Model: 323 Sensor(s). Model: 323 ® Shearvalve(s). M 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 IS Alarm history report 11 Technician Name(print): David Winkler Signature: V Certificafion No.: 5263373-UT License No: 06-1739 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0112 Testing Company Address: 416 2n0 STREET GALT CA 95632 Date of Testing/Servicing: 2-9-2016 Monitoring System Certification Page 1 of 4 2/21/07