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Appendix VI *RECEIVED MONITORING SYSTEM CERTIFICATION OCT 1 1 2016 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 repor�rr�}yS)t, prp��rpd,) ^L HEALTH monitoring system control panel by the technician who performs the work.A copy of this form must be p 1 owner/operator.The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 dJCda ENT A. General Information Facility Name: FLAG CITY CHEVRON Bldg.No.: Site Address: 6421 CAPITAL City: LODI 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: 9/26/2016 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: TanklD: 87 TanklD: 91 N In-Tank Gauging Probe. Model MAG 1 ® In-Tank Gauging Probe. Model: MAG 1 N Annular Space or Vault Sensor. Model. 409 ® Annular Space or Vault Sensor. Model: 409 N Piping Sump/Trench Sensor(s). Model: 208 ® Piping Sump/Trench Sensor(s). Model: 208 N Fill Sump Sensor(s). Model: 208 ® Fill Sump Sensor(s). Model: 208 N 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 N In-Tank Gauging Probe. Model: MAG 1 N In-Tank Gauging Probe. Model: MAG 1 N Annular Space or Vault Sensor. Model: 409 N Annular Space or Vault Sensor. Model: 409 N Piping Sump/Trench Sensor(s). Model: 208 N Piping Sump/Trench Sensor(s). Model: 208 N Fill Sump Sensor(s). Model: 208 N Fill Sump Sensor(s). Model: 208 N Mechanical Line Leak Detector. Model: LD 2000 N Mechanical Line Leak Detector. Model: PE PETRO ❑ Electronic Line Leak Detector. Model: N 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 N Dispenser Containment Sensor(s). Model: 208 N Dispenser Containment Sensor(s). Model: 208 N Shear Valve(s). N 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 N Dispenser Containment Sensor(s). Model: 208 N Dispenser Containment Sensor(s). Model: 208 N Shear Valve(s). N Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). DispenserlD: 9-10 DispenserlD: 11-12 N Dispenser Containment N Dispenser Containment Sensor(s). Model: 208 Sensor(s). Model: 208 N Shear Valve(s). N 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 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): N System set-up N Alarm history report Technician Name(print): FELIX RAMIREZ Signature: Certification No.: 834976 License No: 5273934-UT 08-1740 OTTL Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 2nd STREET GALT,CA 95632 Date of Testing/Servicing: 09-26-16 Monitoring System Certification Page 1 of 2/21/07