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• • RECEIVEC Appendix VI MONITORING SYSTEM CERTIFICATION AUG 2 5 2015 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,California Code of l t�tONMENTAL This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be prepared-farrA—iuVr1CO04TeACk,IT 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 Name: MY MINI MART Bldg.No.: Site Address: 1756 N WILSON WAY City: STOCKTON Zip: Facility Contact Contact Phone No.: (776)421-9978 Person: Dhant or Vinod Make/Model of Monitoring System: INCON 1001 Date of Testing/Servicing: 06-25-15 B. Inventory of Equipment Tested/Certified Check the aEEropriate boxes to indicates ecific equipment ins ectad/serviced: TanklD: 87 TanklD: 91 ® In-Tank Gauging Probe. Model: MAG ® In-Tank Gauging Probe. Model: MAG ® Annular Space or Vault Sensor. Model: ELS ® Annular Space or Vault Sensor. Model: ELS ® Piping Sump/Trench Sensogs). Model: ULS ® Piping Sump/Trench Sensor(s). Model: ULS ❑ 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: FLAPPER ® Tank Overfill/High-Level Sensor. Model: FLAPPER ❑ 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: ❑ 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 Senors). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). 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: ❑ Tank Overfill l 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). DispenserlD: 1.2 DlspenserlD: 3-4 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). IN Shear Valve(s). ® Dispenser Containment Floats)and Chain(s). ® Dispenser Containment Float(s)and Chain(s). DispenserlD: DispenserlD: ❑ Dispenser Containment Sansone). Madel: ❑ 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: Dispenser ID: ❑Dispenser Containment ❑ Dispenser Containment Sensors). Model: Sensor(s). Model: ❑ 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): FELIX RAMIREZ Signature: Certification No.: 5273934-UT License No: 08-1740 Testing Company Name: AFFORDA-TEST Phone No. (2o9)744-0113 Testing Company Address: 416 2 STREET GALT CA 95632 Date of Testing/Servicing: 06-25-15 Monitoring System Certification Pagel of 4 2/21/07