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• Appendix VI RECEIVED MONITORING SYSTEM CERTIFICATION y 2016 For Use By All Jurisdictions Within the State of California SEP 2 Authority Cited: Chapter 6.7,Health and Safety Code; Chapter 16, Division 3,Title 23,California Code of Regulations This form mustbe yused to document testing and servicing ofmonitoringequipment.Pseparate certification or report t r 1q>�gLTH each monitoring system control panel b the technician who performs the work.A co of this form must {b'+H�,/.a, s owner/operator.The owner/operator must submit a copy of this form to the local agency regulating UST s ra ems vvItl L*AVMA iTe. A. General Information UU CC.�� Facility Name: MY MINI MART Bldg.No.: Site Address: 1756 N. WILSON WAY City: STOCKTON Zip: 95205 Facility Contact Person: Contact Phone No.: ( ) Make/Model of Monitoring System: INCON 1001 Date of Testing/Servicing: 6/28/2016 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates ecific equipment ins ectad/serviced: Tank ID: 87 Tank Size: Tank ID: 91 Tank Size: ® In-Tank Gauging Probe. Model: MAG H In-Tank Gauging Probe. Model: M A G H Annular Space or Vault Sensor. Model: EIS H Annular Space or Vault Sensor. Model: SHARED VESSEL H Piping Sump/Trench Sensor(s). Model: U L S H Piping Sump/Trench Sensor(s). Model: U L S ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: H Mechanical Line Leak Detector. Model: 99 LD 2000 H 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 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 Sensogs). 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 an Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). Dispenser ID: I / 2 Dispenser ID: 3 / 4 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). H Shear Valve(s). H Dispenser Containment Floats)and Chain(s). H Dispenser Containment Floats)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats)and Chain(s). ❑ Dispenser Containment Float(s)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 thatthe 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 comet 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 H Alarm history report Technician Name(print): ZANE NIMMO Signature: Certification No.: A28446 License No: 64-1676 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 2nO STREET GALT,CA 95632 Date of Testing/Servicing: 6/28/2016 Monitoring System Certification Page 1 of 2/21/07