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- U Appendix VI M MONITORING SYSTEM CERTIFICATION c 0 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 oft Regulations =i This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be prepared forC=) L each monitoring system control panel by the technician who performs the work.A copy of this form must be provided to the tank system G= o 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. 10 A. General Information T y Facilityyg SHELL Bldg.No.: W. Site Cit STOCKTON Zip: 95212 AddrPcc• 7700 MORELAND RD Y Facility Contact ANGLE Ptarcnn Contact Phone No.: (209)957-5398 Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 9/24/2009 B. Inventory of Equipment Tested/Certified Check the aepropriate boxes to indicate specific equipment inspected/serviced: Tank ID. 87 Tank ID: NIA ® In-Tank Gauging Probe. Model: MAG 1 ❑ In-Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 302 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump/Trench Sensor(s). Model: 208 ❑ Piping Sump/Trench Sensor(s). Model: ® Fill Sump Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ 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: ❑ 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: DIE Tank ID 91 ® In-Tank Gauging Probe. Model: MAG 1 ® In-Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 302 ® Annular Space or Vault Sensor. Model: SAME TANK ® Piping Sump/Trench Sensor(s). Model: 208 ® Piping Sump I Trench Sensor(s). Model: 208 ® Fill Sump Sensor(s). Model: 208 ® Fill Sump Sensor(s). Model: 208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: PLLD ® 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) Dispenser ID: 112 Dispenser ID: 3/4 ® Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model: 208 ® Shear Valve(s). ® 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 ® Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model: 208 ® Shear Valve(s). ® 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 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): ®System set-up ®Alarm history report Technician Name(print): ZANE NIMMO Signature: Certification No.: A28446 License No: 04-1676 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 2'a STREET GALT,CA 95632 Date of Testing/Servicing: 9/24/09 Monitoring System Certification Page 1 of 4 2/21/07 .S6 C