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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. General Information Facility WATERLOO SHELL Bldg. No.: Names• 9• Site Address: 4315 E WATERLOO RD City: STOCKTON CA Zip: Facility Contact Person: RUPI Contact Phone No.: (209) 814-5576 Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 104-2011 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: 87 OCT Tank ID: 91 OCT Z In -Tank Gauging Probe. Model: MAG 1 Z In -Tank Gauging Probe. Model: MAG 1 Z Annular Space or Vault Sensor. Model: 302 Z Annular Space or Vault Sensor. Model: 302 Z Piping Sump / Trench Sensogs). Model: 208 & 304 Z Piping Sump I Trench Sensor(s). Model: 208& 304 Z Fill Sump Sensor(s). Model: 208 &304 Z Fill Sump Sensor(s). Model: 323 &304 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: PLLD Z Electronic Line Leak Detector. Model: PLLD ❑ Model: ❑ 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: Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump /Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Cl 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 Z Dispenser ContainmentSensor(s). Model: 208 AND 304 Z DispenserContainmentSensor(s). Model: 208 AND 304 ❑ Shear Valve(s). Z Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 3-4 Dispenser ID: 7-8 Z Dispenser Containment Sensor(s). Model: 208 AND 304 Z Dispenser Containment Sensor(s). Model: 208 AND 304 Z Shear Valve(s). Z Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: VENT SUMP Dispenser ID: ❑ Dispenser Containment XX Dispenser Containment Sensor(s). Model: 208 AND 304 Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). It me tacnity Contains more tanks or dispensers, copy this tocol. Include mtormation for every tank and dispenser at the tacility. 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; (cheek all that apply): (@ System set-up Z Alarm history report Technician Name (print): DAVE WINKLER Certification No.: 5263373 -UT Testing Company Name: AFFORDA-TEST Testing Company Address: 4182"0 STREET GALT, CA 95632 Signature: V',- _ -) License No: 08-1739 Phone No. (209) 7440113 Date of Testing/Servicing: 10-4-11