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Appendix VI MONITORING SYSTEM CERTIFICATION RECEIVED 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 Cote 2 8 2018 Regulations This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be preparetWVIRONMENTAL each monitoring system control panel by the technician who performs the work.A copy of this form must be provided to the tank sy�¢C)Q�TI..I DEPARTMENT owner/operator.The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of des da e. A. General Information Facility ti,m MY MINI MART Bldg.No.: Site 1756 N WILSON WAY city: STOCKTON zip: 95205 Address P Facility Contact Person, DERK SINGH Contact Phone No.: (916)941-2264 Make/Model of Monitoring System: INCON TS 1001 Date of Testing/Servicing: 6/16/2018 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: 87 Tank Size: Tank ID: Tank Size: ® 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 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: 99 LD 2000 ® Mechanical Line Leak Detector. Model: 99 LD 200 ❑ 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 Size: Tank ID: Tank Size: ❑ 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: ❑ 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/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: I-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: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Vaive(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID DispenserlD: ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s). 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): Ed Steams Signature: Certification No.: A31048 License No: Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 2"d STREET GALT,CA 95632 Date of Testing/Servicing: 6/15/18 Monitoring System Certification Page 1 of 4 2/21/07