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RECEIVED Appendix ONiTORING SYSTEM CERTIFICATION2018 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 ENVIE 9NMENTAL This form must be used to document testing and servicing of monitoring equipment. A separate certification or report mustppprepared each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to tli� t A6T*40FPA RTMFNT owner/operator. The owner/operator must submit a copy of this form to the local agency regulating LIST systems within 30 days of test date. A. Generallnformation Facility Name: Site Address: Facility Contact Person: FOOD MART GAS Bldg. No.: 2185 E. FREMONT STREET city: STOCKTON Make/Model of Monitoring System: VEEDER ROOT TLS -350 Contact Phone No.: B. Inventory of Equipment Tested/Certified Rhnrlr tha annrnnriata hnvas fn indientp_ snprifir. Prujinment insnected/serviced: Z;p: 95205 Date of Testing/Servicing: 9�6�2018 `If the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the Tank ID: 87 OCT Tank Size: 12 K Tank ID: Tank Size: ❑ In -Tank Gauging Probe. Model: N In -Tank Gauging Probe. Model M A G 1 N Annular Space or Vault Sensor, Model: 4 2 0 ❑ Annular Space or Vault Sensor, Model: N Piping Sump /Trench Sensor(s). Model: 2 0 8 ❑ Piping Sump/ Trench Sensor(s). Model: ® Fill Sump Sensor(s), Model: 2 0 8 ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: 99 LD 2000 ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector, Model: N Tank Overfill / High -Level Sensor. Model: M A G I ❑ 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: DIESEL Tank Size: 5 K Tank ID: 91 OCT Tank Size: 5 K N In -Tank Gauging Probe, Model: M A G 1 N In -Tank Gauging Probe, Model: MA G 1 N Annular Space or Vault Sensor, Model: SHARED VESSEL ® Annular Space or Vault Sensor, Model: SHARED VESSEL ® Piping Sump/ Trench Sensor(s). Model 2 0 8 N Piping Sump/ Trench Sensor(s). Model: 2 0 8 N Fill Sump Sensor(s), Model: 2 0 8 N Fill Sump Sensor(s), Model: 2 0 8 N Mechanical Line Leak Detector. Model 99 LD 2000 N Mechanical Line Leak Detector, Model: STP -MLD ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector, Model: N Tank Overfill / High -Level Sensor, Model M A G -T 1 N Tank Overfill / High -Level Sensor, Model M A G I ❑ 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 ®Dispenser Containment Sensor(s), Model: 2 0 8 N Dispenser Containment Sensor(s). Model: 2 0 8 ® Shear Valve(s). N Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5 6 DispenserlD: % 8 N Dispenser Containment Sensor(s), Model: 2 0 8 N Dispenser Containment Sensor(s), Model: 2 0 8 N Shear Valve(s). N Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). raailcy. 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): ® System set-up ®Alarm history report Technician Name (print): ZANE NIMMO Signature: Certification No.: A28446 License No: 04-1676 Testing Company Name: AFFORDA-TEST Testing Company Address: 416 2nd STREET GALT, CA 95632 Phone Da No. (209) 744-0112 te of Testing/Servicing: 9/6/2018 Monitoring System Certification Page 1 of 4 2/21/07