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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 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: CHEROKEE LANE SERVICE STATION Bldg. No.: Site Address: 900 S. CHEROKEE LN City: LODI Zip: 95240 Facility Contact Person: DALJIT Contact Phone No.: (209) 334-3129 Make/Model of Monitoring System: INCON Date of Testing/Servicing: 10/28/2014 B. Inventory of Equipment Tested/Certified Check the annrnnriatp hnwps to indiratp snprifir Pnuinment insnerted/cervired- aFIECEIVED JAN 3 0 2015 ENVIP RM�SERVICESLTH Tank ID: 87-A Tank Size: Tank ID: 87-B ® !n -Tank Gauging Probe. Tank Size: Model: STDiOi ® In -Tank Gauging Probe. Model: STD -101 ® Annular Space or Vault Sensor. Model: TSP-ULS ® Annular Space or Vault Sensor. Model: TSP-ULS ❑ Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector, Model: 116-056 0 Mechanical Line Leak Detector. Model: 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: DIE Tank Size: Tank ID: 91 Tank Size: ® In -Tank Gauging Probe. Model: STD -101 ® In -Tank Gauging Probe. Model: STD -101 ® Annular Space or Vault Sensor. Model: TSP-ULS ® Annular Space or Vault Sensor. Model: TSP-ULS ❑ Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: LD -2000 ® Mechanical Line Leak Detector. Model: LD2000 ❑ 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 Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: lK Shear Valve(s). ® Shear Valve(s). ® Dispenser Containment Float(s) and Chain(s). ® Dispenser Containment Float(s) and Chain(s). [Dis.penserID: 5/6 Dispenser ID: 7/8 penser Containment Sensor(s). Model: n Dispenser Containment Sensor(s). Model: ® 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: 9 -SAT 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). `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 app/v): ® System set-up ® Alarm history report Technician Name (print): Ed Stearns Signature: Certification No.: A31048 License No: Testing Company Name: AFFORDA-TEST Phone No. X09) 744-0113 Testing Company Address: 416 2" STREET GALT, CA 95632 Date of Testing/Servicing: 10/29/14 Monitoring System Certification Page 1 of 4 2/21/07 •