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RECEI % "5 D Appendix VI MAY 2 8 201'MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6 7, l y Code; Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to ocur�►rt �o ��!!ggor�� of monitoring equipment. A separate certification or report must be prepared for each monitoring system control a l b th�`#echTian 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 1,1 CHEROKEE LANE SERVICE Site Arlrlrccc900 S. CHEROKEE LANE Facility Contact Parcnn Make/Model of Monitoring System: INCON TMS 550 Bldg. No.: City: LODI Contact Phone No.: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific a uipment inspected/serviced: zip: 95240 Date of Testing/Servicing: 10-29-2012 Tank ID: 87 A Tank Size: Tank ID: 91 Tank Size: ® In -Tank Gauging Probe. Model: MAG ® In -Tank Gauging Probe. Model: MAG ® Annular Space or Vault Sensor. Model: ULS ® Annular Space or Vault Sensor. Model: SAME AS 87 A ® Piping Sump / Trench Sensor(s). Model: ULS ® Piping Sump / Trench Sensor(s). Model: ULS ❑ Fill Sump Sensor(s). Model: ❑ Fil•. Sump Sensc; (s). Mlodei: ® Mechanical Line Leak Detector. Model: STP -MLD ® Mechanical Line Leak Detector. Model: 99 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: 87 B Tank Size: ® In -Tank Gauging Probe. Model: MAG ® In -Tank Gauging Probe. Model: MAG ® Annular Space or Vault Sensor, Model: ULS ® Annular Space or Vault Sensor. Model: SAME AS DIE ® Piping Sump / Trench Sensor(s). Model: ULS ® Piping Sump / Trench Sensor(s). Model: ULS ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: FX -1 V -D ® Mechanical Line Leak Detector. Model: RJ- XL -P JI Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model. ❑ Tank Overfill / High -Level Sensor. Model: [_i Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). N Uispenser ID: 1/2 Dispenser ID: 3/4 ❑ Dispenser Containment Sensor(s). Model: ❑ 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: 5/6 Dispenser ID: 7/8 ❑ Dispenser Containment Sensor(s). Model: ❑ 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). Uispenser iia: y/iu Dispenser ID: 9 SATELITE NO'I IN SLRVICE ❑ 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 apply): ❑ System set-up ❑ Alarm history report echnician Name (print): David Winkler Signature: q-0--i Certification No.: A28446 License No: 04-1676 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 Testing Company Address: 416 2'0 STREET GALT, CA 95632 Date of Testing/Servicing: 10-29-12 Monitoring System Certification Page 1 of 4 2/21/07