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Appendix VI MONITORING SYSTEM CERTIFICATION 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 test date. A. General Information Facility QUICKI KLEEN CAR WASH Bldg.No.: Nam `� Site 707 YOSEMITE BLVD. City: MANTECA Zip: 95336 Address' Facility Contact Contact Phone No.: ( ) Person' Maka/Model of Monitoring System: Date of Testing/Servicing: 10/2412012 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment ins ectad/serviced: Tank ID: 87 A Tank Size: Tank ID: 89 Tank Size: ® In-Tank Gauging Probe. Model: MARGO M In-Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 420 ® Annular Space or Vault Sensor. Model: ® Piping Sump/Trench Sensor(s). Model: 208 ® 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: ❑ Omer(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: DIE Tank Size: Tank ID: 91 Tank Size: ® In-Tank Gauging Probe. Model: MARGO ® In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ® Annular Space or Vault Sensor. Model: ® Piping Sump/Trench Sensor(s). Model: 208 ® Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensoria). Model: ® Mechanical Line Leak Detector. Model: STP-MLD-D ❑ 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). Dispenser ID: 1 / 2 Dispenser ID: 3 /4 ® Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model'. 208 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Heads)and Chain(s). ❑ Dispenser Containment Floal(s)and Chain(s). Dispenser ID: 5/6 Dispenser ID: 7/8 ID Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Senscr(s). Model: 208 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Floats)and Chain(s). Dispenser ID: Dispenser ID: ❑Dispenser Containment ❑ Dispenser Containment Sensoria). Model: Sensor(s). Model: ❑ Shear Valve(s). ❑Shear Valve(s). ❑ Dispenser Containment Floats)and Chemist. ❑Dispenser Containment Floats)and Chain(s). 'If the facility wntains more tanks or dispensers,copy this torn. 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 elf that apply): ®System set-up ®Alarm history report Technician Name(print): ZANENIMMO Signature: ! Certification No.: A28446 License No: 04-1676 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 2 STREET GALT,CA 95632 Data of Testing/Servicing: 10/24/12 Monitoring System Certification Page 1 of 4 2/21/07