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RECEIVED 0 Appendix VI J; !I 0 ? 2016 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California /VT ) Authority Cited:Chapter 6.7,Health and Safety Code;Chapter 16,Division 3,Title 23, California Code of Retln A..HEALTH This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be prepared for oERVICES each monitoring system control panel by the technician who performs the work.A copy of this form must be provided to the tank system 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: 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 Monitonng System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 2/812016 B. Inventory of Equipment Tested/Certlied Check the appropriate boxes to indicate specific equipment inspectecilserviced: 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 2ao 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 Overall/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). 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: I] 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 10: 1-2 Dispenser 10: 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 Float(s)and Chain(s). Dispenser ID: 34 DispenserlD: 9-10 ❑ Dispenser Containment Sensor(s). Model: 323 ® Dispenser Containment Senscr(s). Model: 323 ❑ Shear Valve(s). ® Shear Valve(s). G Dispenser Containment Fioat(s)and Chain(s), G Dispenser containment Float(s)and Chain(s). Dispenser ID: 5.6 DispenserlD: 11-12 ® Dispenser Containment s Model: 323 ® Dispenser Containment Sensor(s), Model: 323 Sensor(s). ® 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 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 verity that this information is correct and a Plot Plan showing the layout of monitoring equipment.For any equipment"Pablo of generating such reports,I have also attached a copy of the report;(check all Char apply): ®System set-up ®Alarm history report Technician Name(print): David Winkler Signature: Certification No.: 5263373-UT honee . 08-1739 P Testing Company Name: AFFORDA-TEST Phone No. (209)744-0112 Testing Company Ado : 416 2n°STREET GALT,CA 95832 Date of Testing/Servicing: 241-2016 Monitoring System Certification Pagel of 4 2121107