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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 Na WATERLOO SHELL Bldg. No.: Site Addrace, 4315 E WATERLOO RD City: STOCKTON CA Zip: Facility Contact Parcnn- RUPI Contact Phone No.: (209) 814-5576 Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing. 11512010 B. Inventory of Equipment Tested/Certified Check the a❑❑ro❑riate boxes to indicate specific eauiciment inspected/serviced: Tank ID 87 OCT Tank ID: 91 OCT E In -Tank Gauging Probe. Model: MAG 1 E 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 / Trench Sensor(s). Model: 208 E Piping Sump I Trench Sensor(s). Model: 208 E Fill Sump Sensor(s). Model: 208 E Fill Sump Sensor(s). Model: 323 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. I, Model: ® Electronic Line Leak Detector Model: PLLD ® Electronic Line Leak Detector. Model: PLLD ❑ TANK BRINE INTERSTITIAL. Model: 304 ❑ TANK BRINE INTERSTITIAL. Model: 304 ❑ 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 E 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 Ftoat(s) and Chain(s). — I, Dispenser ID: 3-4 Dispenser ID: 7-8 Ii E 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 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: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Ploat(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 J: 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. (209) 744-0113 Testing Company Address: 416 Z STREET GALT, CA 95632 Date of Testing/Servicing: 1-5-2010 Monitoring System Certification Page 1 of 4 2/21/07 L000/Z0001j 9TTO VVL 60Z XVd ET:9T OTOZ/RO/ZO