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RECEIVED Appendix VI MONITORING SYSTEM CERTIFICATION NOV 0 12017 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 otf�Regulations This form must be used to document testing and servicing of monitoring equipment.A separate certification or r VbF-r-I fep%Ped NTAL HEALTH each monitoring system control panel by the technician who performs the work.A copy of this form must be provided to the tank system-t, ENT 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 ARCO Bldg.No.: Site Address: 900 S CHEROKEE LANE City: LODI Zip: 96240 Facility Contact Person: DALJIT Contact Phone No.: (209)334-3129 Make/Model of Monitoring System: TS 5000 Date of Testing/Servicing: 10-17-16 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: 87 Tank ID: 87 N In-Tank Gauging Probe. Model: MAG N In-Tank Gauging Probe. Model: MAG N Annular Space or Vault Sensor. Model: 101 N Annular Space or Vault Sensor. Model: 101 N Piping Sump/Trench Sensor(s). Model: ULS N Piping Sump/Trench Sensor(s). Model: ULS ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: N Mechanical Line Leak Detector. Model: 99 LD 2000 N Mechanical Line Leak Detector. Model: FX1 V ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: N Tank Overfill/High-Level Sensor, Model: FLAPPER N Tank Overfill/High-Level Sensor. Model: FLAPPER ❑ 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: 91 Tank ID: DIE N In-Tank Gauging Probe. Model: MAG N In-Tank Gauging Probe. Model: MAG N Annular Space or Vault Sensor. Model: 101 N Annular Space or Vault Sensor. Model: 101 N Piping Sump/Trench Sensor(s). Model: ULS N Piping Sump/Trench Sensor(s). Model: ULS ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: N Mechanical Line Leak Detector. Model: 99 LD 2000 N Mechanical Line Leak Detector. Model: 99 LD 2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: N Tank Overfill/High-Level Sensor. Model: FLAPPER N Tank Overfill/High-Level Sensor. Model: FLAPPWER ❑ 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. N Shear Valve(s). N ShearValve(s). N Dispenser Containment Float(s)and Chain(s). N 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). N Shear Valve(s). N Dispenser Containment Float(s)and Chain(s). N Dispenser Containment Float(s)and Chain(s). Dispenser ID: 9-10 Dispenser ID: 11 ❑Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: Sensor(s). Model: N Shear Valve(s). ®Shear Valve(s). N 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): ❑System set-up ❑Alarm history report Technician Name(print): FELIX RAMIREZ Signature: '/f Certification No.: 5273934-UT License No: 08-1740 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 2nd STREET GALT CA 95632 Date of Testing/Servicing: 10-17-16 Monitoring System Certification Page 1 of 4 2/21/07