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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 ownefloperator,The cwnerloperator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General information Facility DELTA ARCO Bldg.No.. hi—v Site440 W CHARTER WAY City: STOCKTON Zlp: 85210 Addrwac Facility Contact MAJOR SINGH Contact Phone No.: (209)601 4312 _ PArsnn Make/Model of Monitoring System: GILBARCO EMC Date of Tasting/Servicing: 7/282010 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates eciflc a of ment ins ectad/serviced: Tank iD'. 87 Tank Size: Tank ID: 91 Tank Size: ® In-Tank Gauging Probe. Model: MAG 2 ® In-Tank Gauging Probe, Model: MAG 2 • Annular Space or Vault Sensor. Model 460 ® Annular Space or Vault Sensor. Model: 420 • Piping Sump/Trenen Sensor(s), Model. 208 ® Piping Sump/Trench Sensor(s). Model: 208 ❑ Fill Sump Sensorts), Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: STP MLO Mechanical Line Leak Detector. Model: LD 2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Lava!Sensor. Model ❑ Tank Overfill I 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: DIE Tank Size: Tank 1D: Tank Size ❑ 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: 0 Piping Sump/Trench Sensor(s). Model: C1 Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: C1 Mechanical Line leak Detector, Model: ElMechanical Line Leak Detector. Model: 711 Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Motlel: El Tank Overfill/High-Level Sensor Model: ❑ Tank Overfill/High-Level Sensor. Model: El Other(specify equipment type and model in Section E on Page 2) Q Other(specify equipment type and model In Section E on Page:). Dispenser ID: 1&2 Dispenser ID: 586 0 Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model: 208 ❑ Shear Valve(s) ❑ Shear Velvets). ❑ Dispenser Containment Float(&)and Chaln(s). Q Dispenser Containment Float(s)and Chain(s). _ M Dispenser ID: 3114 1 Dispenser ID: 7&8 ® Dispenser Containment Sensor(s). Moder 208 ® Dispenser Containment Sensor(s) Model. 208 u ❑ Shear Valves) ❑ Shear Valve(s). i ❑ Qispensar Conlslnment Fioat(s)and Chain(s). ❑ Dispenser Containment Flcat(s)and Chain(s). i, Dispenser ID; Dispenser 10: ' ❑ Dispenser Containment � ❑ Dispenser Containment Sensor(&). Model: Sensor(s). Model; ❑ Shear Vatve(s). Q Shear Valve(s). C] Dispenser Containment Floats)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/sarvlced In accordance with the manufacturers' guidelines.Attached to this Certification la Information ment For amara pment ais b)ie ceyto verify th t this sI I have also formation I ttac correct a and a Plot Plan showing t"layout of monitorin�oq p y D generating copy of the report;(check all Char apph); Systitim set-up Alarm history report Technician Name(print): LYLE D NIMMO Signature: ,_ Certification No. OTTL#9i0-1143 License No: ICAC##522 91115UT Phone No. 209)744-0119 — Testing Company Name:AFFORDA-TEST _ M - — Testing Company Address: 416 2 STREET GALT,CA 95632 _ Date of Tenting/Servicing7/28/10 .. Monitoring System Certification Page 1 of d 2/21/07 if„ ,l/. ...A