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Appendix VI RECEIVED MONITORING SYSTEM CERTIFICATION FEB 2 2 2011 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 ENVIRONMENTAL HEALTH Regulations PERMIT/SERVICES 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: GAS 4 LESS Bldg.No.: Site Address: 3434 MANTHEY RD City: STOCKTON Zip: 95206 Facility Contact Person: GILBERT Contact Phone No.: (209)9927620 Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 02-10-11 B. Inventory of Equipment Tested/Certified _Check the appropriate boxes to indicate specific equipment inspected/serviced: LL__nkD 87 Tank ID: 91 In-Tank Gauging Probe. Model: MAG 1 ® In-Tank Gauging Probe. Model: MAG 1 ular Space or Vault Sensor. Model: 420 ® Annular Space or Vault Sensor. Model: g Sump/Trench Sensor(s). Model: 208 ® Piping Sump/Trench Sensor(s). Model: 208 ump Sensor(s). Model: 208 ® Fill Sump Sensor(s). Model: 208 hanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: tronic Line Leak Detector. Model: PLLD ® Electronic Line Leak Detector. Model: PLLD Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: r(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: k Gauging Probe. Model: ❑ in-Tank Gauging Probe. Model: r Space or Vault Sensor. Model: ❑ Annular Space or VaultSensor. Model: Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: mp Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: nical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: nic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: verfill/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 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 Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 9-10 Dispenser ID: ❑ Dispenser Containment ® Dispenser Containment Sensor(s). Model: 208 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 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 apple): ❑System set-up ❑Alarm history report Technician Name(print): FELIX RAMIREZ Signature: �ry<:—• Certification No.: 5273934-UT License No: 08-1740 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 -- Testing Company Address: 416 2" STREET GALT,CA 95632 Date of Testing/Servicing: 02-10-11 Monitoring System Certification Page 1 of 4 2/21/07 I J�