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Appendix VI RECEivEr MONITORING SYSTEM CERTIFICATION APR 2 0 2015 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 CodIN'This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must bi each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system `7"Dt pr• era rT 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: Site Address: WATERLOO SHELL 4315 E. WATERLOO RD Facility Contact Person: RUPI Make/Model of Monitoring System: VEEDER ROOT TLS -350 Bldg. No.: City: STOCKTON zip: 95205 R Contact Phone No.: ( ) Date of Testing/Servicing: 4/2/2015 B. Inventory of Equipment Tested/Certified Char.k the annrnnriate hnYas to indicates snar-ifir anuinmant insnected/serviced: Tank ID: 87 Tank Size: Tank ID: 91 Tank E In -Tank Gauging Probe. Size: Model: MAG I 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 / Trench Sensor(s). Model: 208 E Fill Sump Sensor(s). Model: 208 E Fill Sump Sensor(s). Model: 208 ❑ 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 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: Tank Size: Tank ID: ❑ In -Tank Gauging Probe. Tank Size: 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 / 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: I & 2 DispenserlD: 3 & 4 E Dispenser Containment Sensor(s). Model: 208 E Dispenser Containment Sensor(s). Model: 208 E Shear Valve(s). E Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID. 3 & 6 Dispenser ID: 7 & 8 E Dispenser Containment Sensor(s). Model: 208 E Dispenser Containment Sensor(s). Model: 208 E Shear Valve(s). E Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: Sensor(s). Model: ❑ Shear Valve(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 torm. Incluae information for every tank and dispenser at the tacmry. 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): E System set-up E Alarm history report Technician Name (print): ZANE NIMMO Signature:, —, Certification A28446 License No: 04-1676 No.: Testing Company AFFORDA-TEST Phone No. (209) 744-0113 Name: Testing Company Address: 416 2- STREET GALT, CA 95632 Date of Testing/Servicing: 4/2/2015 Monitoring System Certification Page 1 of 4 2/21/07