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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 of 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 W.—CHEROKEE LANE SERVICE site Address: 900 S. CHEROKEE LANE Facility Contact Person- 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 indicate specific equipment inspected/seryiced: Zip: 95240 Date of Testing/Servicing: 10/31/2011 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: ❑ Fill Sump Sensor(s). Model: ® 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 -I V -D ® Mechanical Line Leak Detector. Model: RJ- XL -P ❑ 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: ® 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). Dispenser ID: 9/10 DispenserlD: 9 SATELITE NOT IN SERVICE ❑ 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 - 1 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): ZANE NIMMO Signature: Certification No.: A28446 License No: 04-1676 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 Testing Company Address: 416 Z STREET GALT, CA 95632 Date of Testing/Servicing: 10/31/11 Monitoring System Certification Page 1 of 4 2/21/07