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RECEIVED Appendix VI MONITORING SYSTEM CERTIFICATION JAN 2 6 2016 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 Re 06NMENTAL This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prelqMTH DEPARTMENT each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank 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: 95240 Facility Contact Person: DALJIT Contact Phone No.: (209) 334-3129 Make/Model of Monitoring System: TS 5000 Date of Testing/Servicing: 10-12-15 B. Inventory of Equipment Tested/Certified Check the anorooriate boxes to indicate saecific eauioment inspected/serviced: Tank ID: 87 Tank ID: 87 Z In -Tank Gauging Probe. Model: MAG Z In -Tank Gauging Probe. Model: MAG Z Annular Space or Vault Sensor. Model: 101 Z Annular Space or Vault Sensor. Model: 101 Z Piping Sump / Trench Sensor(s). Model: ULS Z Piping Sump / Trench Sensor(s). Model: ULS ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Z Mechanical Line Leak Detector. Model: 99 LD 2000 Z Mechanical Line Leak Detector. Model: FX1V ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: FLAPPER Z 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 TanklD DIE Z In -Tank Gauging Probe. Model: MAG Z In -Tank Gauging Probe. Model: MAG Z Annular Space or Vault Sensor. Model: 101 Z Annular Space or Vault Sensor. Model: 101 Z Piping Sump / Trench Sensor(s). Model: ULS Z Piping Sump / Trench Sensor(s). Model: ULS ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Z Mechanical Line Leak Detector. Model: 99 LD 2000 Z Mechanical Line Leak Detector. Model: 99 LD 2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Z Tank Overfill / High -Level Sensor. Model: FLAPPER Z 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 Z Shear Valve(s). Z Shear Valve(s). Z 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: Z Shear Valve(s). Z Shear Valve(s). Z Dispenser Containment Float(s) and Chain(s). Z Dispenser Containment Float(s) and Chain(s). Dispenser ID: 9-10 Dispenser ID: 11 ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: Sensor(s). Model: Z Shear Valve(s). Z Shear Valve(s). Z Dispenser Containment Float(s) and Chain(s). Z 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:s Certification No.: 5273934 -UT License No: 08-1740 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 Testing Company Address: 416 2"d STREET GALT, CA 95632 Date of Testing/Servicing: 10-12-15 Monitoring System Certification Page 1 of 4 2/21/07