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RCE' r Appendix VI FEB a $ 201 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California EVV/RONM Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code ° 'til&diEA1TH This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for ( Pt/j('FS 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 Name: WEST LANE CHE Site Address: 4747 WEST LANE Facility Contact Person: RAVINDER Bldg. No.: City: STOCKTON Zip: 95210 Contact Phone No.: (209) 472-1639 Make/Model of Monitoring System: VEEDER ROOT TLS 350 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment incnprtrarl/�zPrvirprt• Date of Testing/Servicing: 09-29-15 Tank ID: 87 Tank ID: 87 E In -Tank Gauging Probe. Model: MAG 1 E In -Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 409 E Annular Space or Vault Sensor. Model 409 E Piping Sump / Trench Sensor(s) Model: 208 E Piping Sump / Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: E Electronic Line Leak Detector. Model: PLLD E Electronic Line Leak Detector. Model: PLLD E Tank Overfill / High -Level Sensor Model: FLAPPER E Tank Overfill / High -Level Sensor. Model: FLAPPER ❑ 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: E In -Tank Gauging Probe. Model: MAG 1 ❑ In -Tank Gauging Probe. Model - 21 Annular Space or Vault Sensor. Model: 409 ❑ Annular Space or Vault Sensor. Model: E Piping Sump / Trench Sensor(s). Model: 208 ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Mcdel: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: PLLD ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor, Model: FLAPPER ❑ 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: 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: 5-6 Dispenser ID: 7-8 E Dispenser Containment Sensor(s). Model: 208 E Dispenser Containment Sensor(s). Model: 208 Shear Valve(s). E Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). DispenserlD: 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 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): E System set-up E Alarm history report Technician Name (print): FELIX RAMIREZ Signature:? Certification No.: 5273934 -UT License No: 08-1740 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 Testing Company Address: 416 2n1 STREET GALT, CA 95632 Date of Testing/Servicing: 09-29-15 Monitoring System Certification Page 1 of 4 2/21/07