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Appendix VI OCT 2 3 2017 MONITORING SYSTEM CERTIFICATION ENVIRONMENTAL HEALTH For Use By All Jurisdictions Within the State of California PERMITISERVICYS 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 Name: FLAG CITY CHEVRON Bldg. No.: Site Address: 6421 CAPITAL City: LODI CA Zip: 95242 Facility Contact Person: KUI Contact Phone No.: (209) 334-0975 Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 9-26-17 B. Inventory of Equipment Tested/Certified Chprk Tho nnnrnnriata hnvpc M infli—tp cnorifir o of i rt -11 on. —4 - Tank ID: 87 Tank ID: 91 ® In -Tank Gauging Probe. Model: MAG 1 ® In -Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 409 ® Annular Space or Vault Sensor. Model: 409 ® Piping Sump/ Trench Sensor(s). Model: 208 ® Piping Sump / Trench Sensor(s). Model: 208 ® Fill Sump Sensor(s). Model: 208 ® Fill Sump Sensor(s). Model: 208 ® Mechanical Line Leak Detector. Model: PE PETRO ® Mechanical Line Leak Detector. Model: PETRO ❑ 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: DIE Tank ID: 87 SYPON ® In -Tank Gauging Probe. Model: MAGI ® In -Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 409 ® Annular Space or Vault Sensor. Model: 409 ® Piping Sump / Trench Sensor(s). Model: 208 ® Piping Sump/ Trench Sensor(s). Model: 208 ® Fill Sump Sensor(s). Model: 208 S Fill Sump Sensor(s). Model: 208 ® Mechanical Line Leak Detector. Model: LD 2000 ® Mechanical Line Leak Detector. Model: PE PETRO ❑ 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 Sensogs). 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. 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 Floats) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 9-10 Dispenser ID: 11-12 ® Dispenser Containment ® Dispenser Containment Sensor(s). Model: 208 Sensor(s). Model: 208 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). IT the Tacuity contains more tanK$ or aispensers, copy tens toren. incivae intormation for every tanK and dispenser at the tacility. 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): DAVE WINKLER Signature: C \ ) Certification No.: B34975 License No: 08-17399 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 Testing Company Address: 416 2nd STREET GALT, CA 95632 Date of Testing/Servicing: 9-26-17 Monitoring System Certification Page 1 of 2/21/07