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Appendix VI MONITORING SYSTEM CERTIFICATION ON.'iENJ,e For Use By All Jurisdictions Within the State of California Pur& r E,�iV',i£e �H�'� Authority Cited:Chapter 6.7,Health and Safety Code;Chapter 16,Division 3,Title 23, California Code of R09 red for 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 Bldg.No.: Facility Name: JSKS MAIN ST ARCO City: LODI CA Zip: Site Address: 1100 S MAIN STREET 93337 Contact Phone No.: ( ) -- Facility Contact Person: Jesse Date of Testing/Servicing: 3/2812017 Make/Model of Monitoring System: VEEDER ROOT TLS 350 B. Inventory of Equipment Tested/Certified Check theappropriate boxes to indicates cific ui ment ins serviced' Tank ID: 91 Size: In-Tank Gauging Probe. Tank Size: Tank Si Tank ID: 87 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: 323 ® Piping Sump/Trench Sensor(s). Model: 323 kAodel: 323 ® Fill Sump Sensor(s). Model: 208 ® Pili Sump Sensor(s). ® Mechanical Line Leak Detector. Model: 99LD 200 ® Mechanical Line Leak Detector. Model: 99LD 2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill I 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 Size: Tank Size: Tank ID: Tank ID: 89 Model: ® In-Tank Gauging Probe. Model: MAG 1 ❑ Annulain r Gauging Probe. ❑ Annular Space or Vault Sensor. Model: ® Annular Space or Vault Sensor. Model: 409 Piping Sump/Trench Sensor(s). Model: ® Piping Sump/Trench Sensor(s). Model: 323 Model: ® Fill Sump Sensor(s). Model: 323 Fill Sump Sensor(s). ❑ Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: FE PETRO ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill I 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: 7-8 Dispenser ID: 1-2 Model: 323 Model: 323 ® Dispenser Containment Sensor(s). ® Dispenser Containment Sensor(s). ® 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: 3-4 Model: 323 Model: 323 ® Dispenser Containment Sensor(s). ® Dispenser Containment Sensor(s). ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Flcat(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 11-12 I Dispenser ID: Dispenser Containment ® Dispenser Containment Sensor(s). Model: 323 Sensor(s). Model: 323 ®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 inspectedlserviced 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 l�ry report generating such reports,I have also attached a copy of the report;(check all that app&): ®System set-up Technician Name(print): David Winkler Signature: License No: 08-1739 Certification No.: 5263373-UT Phone No. 209 744-0112 Testing Company Name: AFFORDA-TEST Date of Testing/Servicing: 3-28-17 Testing Company Address: 415 2n°STREET GALT,CA 95632 2/21/07 Monitoring System Certification Page 1 of 4