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Appendix VI RIECIEVED MONITORING SYSTEM CERTIFICATION NOV 0 6 2009 For Use By All Jurisd ctions Within the State of California ,!,��C Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, Ca ii�V HEALTH Regulations ti IT/SERVICES 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 w rk. 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 I cal agency regulating UST systems within 30 days of test date. A. General Information Facility KI.—CHEROKEE LANES ARCO Site Adriress' 900 S CHEROKEE LANE Facility Contact PP.rCnn, DIDAR Make/Model of Monitoring System: VEEDER ROOT TLS 350 Bldg. No.: City: LODI CA Zip: Contact Phone No.: (209) 334-3129 Date of Testing/Servicing: 10/15/2009 B Inventory of Equipment Tested/Certified Check the annronriate boxes to indicate snecific Poninment inknPcted/serviced- Tank ID: 87 W Tank ID: 87 E ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor, Model: SPLIT ❑ Annular Space or Vault Sensor. Model: SPLIT ® Piping Sump/ Trench Sensor(s). Model: 205 ID Piping Sump / Trench Sensor(s). Model: 205 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: FE PETRO ® Mechanical Line Leak Detector. Model: XLP ❑ 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: 91 Tank ID: DSLO ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 420 ® Annular Space or Vault Sensor. Model: 420 ® Piping Sump / Trench Sensor(s). Model: 205 ® Piping Sump / Trench Sensor(s). Model: 205 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: LD -2000 ® Mechanical Line Leak Detector. Model: FXIV 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 in Section E on Page 2). Dispenser ID: 1-2 Dispenser ID: 5-6 ❑ Dispenser Containment Sensor(s). Model: YES ❑ Dispenser Containment Sensor(s). Model: YES ® Shear Valve(s). ® Shear Valve(s). ® Dispenser Containment Float(s) and Chain(s). ® Dispenser Containment Float(s) and Chain(s). DispenserID: 3-4 Dispenser ID: 7-8 ❑ Dispenser Containment Sensor(s). Model: YES ❑ Dispenser Containment Sensor(s). Model: YES ® Shear Valve(s). ® Shear Valve(s). ® Dispenser Containment Float(s) and Chain(s). ® Dispenser Containment Float(s) and Chain(s). Dispenser ID: SAT Dispenser ID: 9-10 ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: YES Sensor(s). Model: YES ® Shear Valve(s). ® Shear Valve(s). ® Dispenser Containment Float(s) and Chain(s). ® Dispenser Containment Float(s) and Chain(s). -It the faculty contains more tanks or alspensers, copy inis torm. Include information for every tank and dispenser at the facility. I C. Certification - I certify that the equipment identified in this document wasInspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is Information (e.g. manufacturer ' checklists) necessary to verify that this Information is correct and a Plot Plan showing the layout of monitoring equipment. For any equi meet 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): Certification No.: 52633 Testing Company Name: Testing Company Address: DAVE WINKLER Monitoring System Certification GALT Signature: License No: 08-1739 Phone No. (209) 744.0113 Date of Testing/Servicing: 10-15-2009 1 of 4 'V_ L 2/21/07.