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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. General Information Facility SUPER CENTER MART Bldg. No.: City: STOCKTON, CA Zip: 95206 Site Address: 701 E. CHARTER WAY Facility Contact Person: Make/Model of Monitoring System: VEEDER ROOT TLS -35C Contact Phone No.: B. Inventory of Equipment Tested/Certified rk 11 fk rin#n r,nvna In ineli—fa anneifir anninmanl inenartad/sarvirpri- Date of Testing/Servicing: 6/6/2011 Tank ID: 87 Tank Size: Tank ID: 91 ® In -Tank Gauging Probe. Tank Size: Model: MAG 7 ® In -Tank Gauging Probe. Model: MAG 7 ® Annular Space or Vault Sensor. Model: 420 ® Annular Space or Vault Sensor. Model: SAME TANK ® Piping Sump /Trench Sensor(s). Model: 208 ® Piping Sump /Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: STP -MLD ® Mechanical Line Leak Detector. Model: FX -1V ❑ 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 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 Sedion E on Page 2). Dispenser ID: 1/2 Dispenser ID: )/4 ® Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s) Model 208 ® Shear Valve(s). ® Shear Valve(s) ❑ Dispenser Containment Fioat(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser 0: 5/6 Dispenser ID: 7/8 ® Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model: 208 ® 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 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 torm. incivae inrormavon Tor every tank and dispenser at cine id—ay. 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): ZANE NIMMO Signature: Certification No.: A28446 License No: 041676 Testing Company Name: AFFORDA-TEST Phone No. (209) 7440113 Testing Company Address: 416 2 STREET GALT, CA 95632 Date of Testing/Servicing: 6/6/11 Monitoring System Certification Page 1 of 4 2/21/07