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Appendix Vl REC'j'IENED MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California AUG 0 9 2017 Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to documnt testing and servicing of monitoring equipment. Apseparate certification or report must be prepared for HEALTH each monitoringsystem control panel b the technician who performs the work. A w of this form must be rgw�gQ tq(�ipyl fry�e f I owner/operator. The owner/operator must submit a copy of this forth to the local agency regulating UST systems GvlhlhVJbrda2'gD$'ETIas a�"MENT A. General Information Facility Name: ORLANDO'S MARKET Bldg. No.: Site Address: 18764 HWY 26 City: LINDEN Zip: 96236 Facility Contact Person: Contact Phone No.: Make/Model of Monitoring System: VEEDER ROOT TLS350 Date of Testing/Servicing: 7-11-2017 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tar lD: 87 TanklD: 91 ® In -Tank Gauging Probe. Model: MAG 1 ® In -Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 420 ® Annular Space or Vault Sensor. Model: 420 ® Piping Sump/ Trench Sensor(s). Model: 208 ® Piping Sump/Trench Sensor(s). Model: 208 ® Fill Sump Sensor(s). Model: 208 ® Fill Sump Sensor(s). Model: 208 ® Mechanical Line Leak Detector. Model: 99LD2000 ® Mechanical Line Leak Detector. Model: 99LD2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: 90% ® Tank Overfill / High -Level Sensor. Model: 90% ❑ Other (specify equipment type and model in Section Eon Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: DIESEL Tar lD: ® In -Tank Gauging Probe. Model: MAG 1 ❑ In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 420 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump / Trench Sensor(s). Model: 208 ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensar(s). Model: ® Mechanical Line Leak Detector. Model: 99LD2000 ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: 90% ❑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. 3-4 ® Dispenser Containment Sensors). Model: 208 ® Dispenser Containment Sensohs). Model: 208 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Cl ❑ Dispenser Containment Float(s) and Cl Dispenser ID: 5-6 Dispenser ID: 7-8 ® Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model: 208 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Floats) and Chain(s). ❑ Dispenser Containment Floats) and Cl 9-10 DispenserlD: 11-12 ED,n: ontainment Sensor(s). MOde1: 208 ® Dispenser Containment Sensor(s). Model: 208 (s). ® ShearValve(s).ontainment Floats) and Chain(s). ❑ Dispenser Containment Floats) and Chairl '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 documentwas 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 alf that apply): ® System set-up ® Alarm history report Technician Name (print): DAVE WINKLER Signature: ) Certcation No.: 5273934 -UT License No: 08-17398 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0112 _. Testing Company Address: 416 2n° STREET GALT, CA 95632 Date of Testlng/Servicing: 7-11-17 Monitoring System Certification Page 1 of 4 2/21/07