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Appendix VI RECEIVED MONITORING SYSTEM CERTIFICATION FEB 087.011 For Use By All Jurisdictions Within the State of California ENVIRONMENTAL HEALTH Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code Of PERMIT/SERVICES 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 ni.— CHEROKEE LANES ARCO Site Bldg. NO.: Adrfracc• 900 S CHEROKEE LANE City: LODI CA Facility Contact Zip: PArSnn• DIDAR Contact Phone No.: 209 3:34-3129 Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 1/26/11 B. Inventory of Equipment Tested/Certified Check the appropriate homes. to inriirntc cnnrifir rr �•••� �� ..�u�o " 1-111auvii wi e%le y Laurc dnu uispenser 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, 1 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.: ICC 5263322UT A28446 License No: 04-1676 Testing Company Name: AHFORDA-TEST Phone No. _(209) 744-0113 Testing Company Address: 416 2" STREET GALT, CA 95632 Date of Testing/Servicing: 1-26.11 -- Monitoring System Certification Page 1 of 4 2/21/07 S3c �-\� VII.CU. Tank ID: 87 Eing FID:W Probe. Model: mag ❑ In -Tank Gauging Probe. Model: MAG e or Vault Sensor. Model: SPLIT❑Annular Space or Vault Sensor. Model: SPLIT / 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: XLP ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2.)._ ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: 91 Tank ID: DSLO ❑ 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: ULS ® 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: LD -2000 ® Mechanical Line Leak Detector. Model: FX IV D ❑ 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 (nSection Eon Page2). Dispenser ID: 1-2 er ID: 5-6❑ Dispenser Containment Sensor(s). Model: EF::: ser Containment Sensor(s). Model: ® Shear Valve(s). Valve(s).® Dispenser Containment Floats) and Chain(s). ser Containment Float(s) and Chain(s). r ID: 7-8 Containment Sensor(s). IVlodel® Dispenser ID: 3-4 ❑ Dispenser Containment Sensor(s). Model:ser Shear Valve(s). Valve(s). Dispenser Containment Float(s) and Chain(s). ser Containment Float(s) and Chain(s). Dispenser ID: SAT Dispenser ID: 9-10 ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: _ Sensor(s). Model: ® Shear Valve(s). ®Shear Valve(s). ® Dispenser Containment Floats) and Chain(s). ® Dispenser Containment Float(s) and Chain(s). `If the facility contains more tanks nr disnonsare — this f,,..., __ rr �•••� �� ..�u�o " 1-111auvii wi e%le y Laurc dnu uispenser 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, 1 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.: ICC 5263322UT A28446 License No: 04-1676 Testing Company Name: AHFORDA-TEST Phone No. _(209) 744-0113 Testing Company Address: 416 2" STREET GALT, CA 95632 Date of Testing/Servicing: 1-26.11 -- Monitoring System Certification Page 1 of 4 2/21/07 S3c �-\�