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• Appendix VI �_watertwards ca.cov.) (Copies of Monitoring System certificaavailable at http�L tion SYSTEMg PlotPlan CERTIFICATIONI 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 Regulations 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 lest date. I JUL y 2' 2013 A. General information Facility Name: MY MINII MART Sidi No.: Site Address: 1756 N WILSON WAY City: STOCKTON CA Zi �r`��;}'��kNTALHEALTH Facility Contact LAL Contact Phone No.: (209)941-2264 �rG{�'U)I i willf9�Cis PP.m0 Make/Model of Monitoring System: INCON 1001 Dale of Testing/Servicing: 612512013 B. Inventory of Equipment Tested/Certified Check thea pro rials boxes to indicate specific equipment inspected/serviced: Tank ID: 67 OCT Tank ID: 91 OCT ® 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: SPLIT ® Piping Sump/Trench Sensor(s). Model: ULS ® Piping Sump/Trench Sensor(s). Model: ULS ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: FXIV ® Mechanical Line Leak Detector. Model: FXIV ❑ 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: ❑ 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 Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Ci Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: C Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: C Tank Overfill I High-Level Sensor. Model: ❑ Tank Overfill I High-Level Sensor. Madel: 0*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). ID Dispenser Containment Float(s)and Chain(s). ® Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Velvets). ❑ Dispenser Containment Float(s)and Chaints). ❑ Dispenser Containment Floats)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 Floats)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 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 that apply): ®System set-up ®Alarm history report 11 Technician Name(print): David A.Winkler Signature: V �� Certification No.: 34975 License No: OTT OB-1739 Testing Company Name. AFFORDA-TEST Phone No. (209)744-0113 Tearing Company Address: 418 2" STREET GALT CA 95832 Date of Tesfing/Servicing: 6-25-13 Monitoring System Certification Page 1 of 4 2/21/07