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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 ,,,,,__ WATERLOO SHELL Site Aridrac¢ 4315 E WATERLOO RD Facility Contact Persnn RUPI Make/Model of Monitoring System. VEEDER ROOT TLS 350 Bldg. No.: City: S70CK70N CA Zip: Contact Phone No.: (209) 814-5576 B. Inventory of Equipment Tested/Certified Check the aporopriate boxes to indicate specific equipment inspected/serviced: Date of Testing/Servicing: 1/5/2010 Tank ID: 87 OCT Tank ID: 91 OCT E In -Tank Gauging Probe. Model: MAG 1 ® In -Tank Gauging Probe. Model: MAG 1 E Annular Space or Vault Sensor. Model: 302 E Annular Space or Vault Sensor. Model: 302 E Piping Sump 1 Trench Sensor(s). Model: 208/304 ® Piping Sump / Trench Sensor(s). Model: 2081304 E Fill Sump Sensor(s), Model: 2081304 E Fill Sump Sensor(s). Model: 323!304 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: E Electronic Line Leak Detector. Model: PLLD E Electronic Line Leak Detector. Model: PLLD ❑ TANK BRINE INTERSTITIAL. Model: ❑ TANK BRINE INTERSTITIAL. 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: ❑ Tank Overfill I 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: 208 AND 304 E Dispenser Containment Sensor(s). Model: 208 AND 304 ❑ Shear Valve(s). E 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 E Dispenser Containment Sensor(s). Model: 208 AND 304 E Dispenser Containment Sensor(s). Model: 208 AND 304 E Shear Valve(s). E Shear Valve(s). ❑ Dispenser Containment Floats) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: VENT SUMP Dispenser ID: ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: 208 AND 304 Sensor(s). Model. ❑ Shearvalve(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 - 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 verity 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 Thar apply): E System set-up E Alarm history report Technician Name (print): DAVE WINKLER Signature: Certification No.: 5263373 -UT License No: 08-1739 Testing Company Name: AFFORDA-TEST Phone No. (20 9) 744-0113 Testing Company Address: 416 2" STREET GALT, CA 95632 Date of Testing/Servicing: 1-5-2010 Monitoring System Certification Page 1 of 4 2/21/07 2000/Z000 Z 9TTO ftL 60Z VV3 9£:LT OTOZ/80/ZO