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4. Appendix VI M RING SYSTEM CERTIFICATION .�p d�ry By All Jurisdictions Within the State of California Authority ited: Chapter 6``''.7,, ij90 1 )RING Chapter 16, Division 3,Title 23, California Code of Regulations This form muss be used to docu��T d servicing of monitoring equipment.A separate certification or report must be prepared for each monitor) system control panel he technician who performs the work.A copy of this form must be provided to the tank system owner/operato.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 I information Facility Bldg.No.: Name: SYSTEM TRANSPORT 9 _. Site Address. 707 EAST ROTH City: FRENCH CAMP Zip: 95237 Facility Contact Person: SAM Contact Phone No.: (209)983-6654 Make/Model of Monitoring System: VEEDER ROOT Ti 300C Date of Testing/Servicing: 05-21-12 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific a uipment ins ectedlseryiced: Tank ID: DIESEL Tank ID: ® In-Tank Gauging Probe. Model: MAG 2 ❑ In-Tank Gauging Probe. Model: ® Annular Space.or Vault Sensor. Model: 407 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump/ITrench Sensor(s). Model: 208 Ll Piping Sump/Trench Sensor(s). Model: E3 Fill Sump Senyor(s). Model: E] Fill Sump Sensor(s). Model: ® Mechanical Li a Leak Detector. Model: LD 2000 ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line.Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill/High-Level Sensor. Model: FLAPPER ❑ 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). Tari TankID: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sermons). 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: [I Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). C] Other(specify equipment type and model in Section E on Page 2). Dispenser ID: ,1 SAT Dispenser ID: 1-2 ® Dispenser Containment Sensor(s). Model, 208 ® Dispenser Containment Sensor(s). Model: 208 ® Shear Valvei ® Shear Valve(s). ❑ Dispenser Containment Floats)and Chain(s). ❑ Dispenser Containment Floats)and Chain(sj. Dispenser ID: 12 SAT Dispenser ID: El Dispenser Co:tainment Sensor(s). Model: 208 ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve( ❑ Shear Valve(s). [IDispenser Co tainment 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: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Hestia)and Chain(s). ❑ Dispenser Containment Floats)and Chairi '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 ®Alarm history report Technician Name(print): FELIX RAMIREZ Signature: er_-C J Certification No.: 5273934-UT License No: 08-1740 .— Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 - Testing Company Address: 416 2 STREET GALT CA 95632 Date of Testing/Servicing: 05-21-12 Monitoring System Certification Page 1 of 4 2/21/07