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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 Atej(ytions 4j This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be preti; tff 2j% each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank syste owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of tesMFjvT General M�r�sFR�c F4�, InformationFacility FS Name: SUPER CENTER MART Bldg. No.: Site Address: 701 E. CHARTER WAY City: STOCKTON Zip: 95206 Facility Contact Person: Make/Model of Monitoring System: VEEDER ROOT TLS -350 Contact Phone No.: ( ) B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Date of Testing/Servicing: 6111/2012 Tank ID: 87 Tank Size: Tank ID: 91 Tank Size: S In -Tank Gauging Probe. Model: MAG 7 S In -Tank Gauging Probe. Model: MAG 7 S Annular Space or Vault Sensor. Model: 420 S Annular Space or Vault Sensor. Model: SAME VESSEL S Piping Sump / Trench Sensor(s). Model: 208 S Piping Sump / Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: S Mechanical Line Leak Detector. Model: STP -MLD S 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: S In -Tank Gauging Probe. Model: S In -Tank Gauging Probe. Model: S Annular Space or Vault Sensor. Model: S Annular Space or Vault Sensor. Model: S Piping Sump / Trench Sensor(s). Model: S 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). Dispenser ID: 1/2 Dispenser ID: 3/4 S Dispenser Containment Sensor(s). Model: 208 S Dispenser Containment Sensor(s). Model: 208 S Shear Valve(s). S Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5/6 Dispenser ID: //8 S Dispenser Conts.nment Sensor(s). Model: 208 ,� 208 S Shear Valve(s). 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). it '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): S System set-up S Alarm history report Technician Name (print): ZANE NIMMO Signature: Certification No.: A28446 License No: 04-1676 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 Testing Company Address: 4162 nSTREET GALT, CA 95632 Date of Testing/Servicing: 6/11/12 Monitoring System Certification Page 1 of 4 2/21/07