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RECEIVE[ Appendix VI JAN 2 9 2015 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California EMIRONMENTAL Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of :c�„ ^.r7PDT.eeslT 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 Facility Contact Person: DALJIT Make/Model of Monitoring System: INCON City: LODI Zip: 96240 Contact Phone No.: (209) 334-3129 Date of Testing/Servicing: 10/28/2014 B. Inventory of Equipment Tested/Certified e+k....� •k- - A. *- r.... f- c rifir o -nf incnnr}or{/co rvicarl• Tank ID: 87-A Tank Size: Tank ID: 87-B Tank Size: N In -Tank Gauging Probe. Model. STD101 E In -Tank Gauging Probe. Model: STD -101 E Annular Space or Vault Sensor. Model: TSP-ULS N 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: E Mechanical Line Leak Detector. Model: 116-056 E 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: E In -Tank Gauging Probe. Model: STD -101 E In -Tank Gauging Probe. Model: STD -101 N Annular Space or Vault Sensor. Model: TSP-ULS N 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: N Mechanical Line Leak Detector. Model: LD -2000 N 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: E Shear Valve(s). E Shear Valve(s). N Dispenser Containment Float(s) and Chain(s). E Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5/6 Dispenser ID: 7/8 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s) Model: N Shear Valve(s). E Shear Valve(s). E Dispenser Containment Float(s) and Chain(s). E 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: E Shear Valve(s). I ® Shear Valve(s). N Dispenser Containment Float(s) and Chain(s). I ® Dispenser Containment Float(s) and Chain(s). 'If the facility contains more tanKs or aispensers, copy oris rorm. incivae mrormauon ror every mnK ana mspensei ar uie iacuny. 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 a// that apply): E System set-up N Alarm history report Technician Name (print): Ed Stearns Signature: Certification No.: A31048 License No: Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 Testing Company Address: 416 2" STREET GALT, CA 95632 Date of Testing/Servicing: 1 Monitoring System Certification Page 1 of 4 2/21/07