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Appendix VI 0 �D ll llEc�C�gVD ll u 60 MONITORING SYSTEM CERTIFICATION MAY Y 7 ZWO 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, Califlo 1tV t� T HEALTH Regulations PERK/SERVICES This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system 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 Information Facility KI.—THORNTON 76 Bldg. No.: Site Addrass 8606 THORNTON RD. _ _ _ _ City: STOCKTON, CA Zip: 95209 Facility Contact Pr:rcnn AMBA Contact Phone No.: (209) 478-8959 Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 5/3/2010 B. Inventory of Equipment Tested/Certified Check the annronriate boxes to indirate snecifir enuinment insnected/serviced: Tank ID: 87 OCT Tank ID: 89 OCT ® In -Tank Gauging Probe. Model: MAG 1 ® In -Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 407 ® Annular Space or Vault Sensor. Model: 407 ® Piping Sump / Trench Sensor(s). Model: 208 ® Piping Sump / Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: 99 LD 2000 ® Mechanical Line Leak Detector. Model: 99 LD 2000 ❑ 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). Tank ID: Tank ID: 91 OCT ® In -Tank Gauging Probe. Model: ® In -Tank Gauging Probe. Model: _ MAG 1 ® Annular Space or Vault Sensor. Model: ® Annular Space or Vault Sensor. Model: 407 ® Piping Sump / Trench Sensor(s). Model: ® Piping Sump / Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: _ ® Mechanical Line Leak Detector. Model: ® Mechanical Line Leak Detector. Model: 99 LD 2000 ❑ 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: 3/4 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ® 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: 7/8 ❑ Dispenser Containment Sensor(s). Model: N/A ❑ Dispenser Containment Sensor(s). Model: N/A ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 9/10 Dispenser ID: 11/12 ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: N/A Sensor(s). Model: N/A ® 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 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): ZANE NIMMO Signature: Certification No.: A28446 License No: 04-1676 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 Testing Company Address: 416 260 STREET GALT, CA 95632 Date of Testing/Servicing: 5/3/10 Monitoring System Certification Page 1 of 4 2/21/07 .: j C c-�