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Appendix VI MONITORING SYSTEM CERTIFICATION JUN 10 2DJa Use By All Jurisdictions Within the State of California Authority C ted:Chapter 6.7,Health and Safety Code;Chapter 16, Division 3,Title 23,California Code of Regulations This form must eyused to dgpamenttest ing'a0?servieing of�onitoring equipment.A separate s form mmust be provided lofication or report ust be se taprepared k a aremfor each monitonn s stem wn rot panel b :the technician whd bbrtortns the work.A copy 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. Generali iformation Bldg.No.: Facility ame: SYSTEM TRANSPORT Site Ad ress: 707 EAST ROTH City: FRENCH CAMP Zip: 95237 FacilityContact Contact Phone No.: (209)983.8654 Person,, SAM Date of Testing/Servicing: 05-23-13 Make/Model of Monitoring System: VEEDER ROOT TLS 300C S. Inventory of Equipment Tested/Certified Check thea propriate boxes to indicatespecific equipment inspected/serviced: Tank ID: Tank ID: DIESELMotlel: ® In-Tank Gauging Probe. Model: MAG 2 ❑ Tank Gauging Probe. [1Annular Space or Vault Sensor. Model: ® Annular Space or Vault Sensor. Model: 407 0 Piping Sump/Trench Sensor(s). Model: ® Piping Sump/Trench Sensor(s). Model: 208 [1 Fill Sump Sensor(s). Model: ❑ Fill Sump Sensoos). Model: ❑ Mechanical Line Leak Detector. Model: ® Mechanical Li a Leak Detector. Model: LD 2000 Electronic Line Leak Detector. Model: ❑ Electronic Ling Leak Detector. Model: ® Tank Overfill High-Level Sensor. Model: FLAPPER ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(sped equipment type and model in Section E on Page 2). 0 Other(specify equipment type and model in Section E on Page 2). TanklD: Tank ID: Model: [3In-TankGauging Probe. Model: ❑ In-Tank Gauging Probe. ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump I Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: E] Fill Sump Se sor(s). Model: ❑ Fill Sump Sensor(s). Model: [( Mechanical 'ne Leak Detector. Model: ❑ Mechanical Line Leak Detector Model: ❑ Electronic Li'"a Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill I High-Level Sensor. Model: El Other(sped.. 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'. 1 SAT ® Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model: 208 ® Shear Valve(s). ® Shear Valve(s). C1 Dispenser Containment Float(s)and Chain(s). Dispenser Containment Floats)and Chains). Dispenser ID: 2 SAT Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ® Dispenser Containment Sensor(s). Model: 208 ❑ Shear Velvets). ® Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Floats)and Chaints). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: El Dispenser Containment Sensor(s). Model: [IShear Valve(s). ❑ Shear Valy,(s ). ❑Dispenser Containment Float(s)and Chain(s). El 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 capable of generating such reports,I have also attached a copy of the report;(check all rhal apply): ❑System set-up M Alarm history report Technician Name(print): FELIX RAMIREZ Signature: { License No: 08-1740 Certification No.. 5273934-UT Phone No. 209 744-0113 Testing Company Name: AFFORDA-TEST Date of Testing/Servicing: 05-23-13 Testing Company Address: 416 2 STREET GALT CA 95632 2/21/07 Monitoring System Certification Pagel of 4 S) cG1`