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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 Cod�Rf V4 Regulations ((..T 2 4 t This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be prepaiiS.Urjr�^ �O�/ each monitoring system control panel by the technician who performs the work.A copy of this form must be provided to the tank systerl j,) Wi, , owner/operator.The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of ,�C A filj;q v A. General Information j�jj Facility Fn'T Name: 99 SHELL Bldg.No.: Site Address: 7700 MORELAND RD City: STOCKTON Zip: Facility Contact Person: ANGLE Contact Phone No.: ( ) Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 08-23-11 B. Inventory of Equipment Tested/Certified Check the ap ro riate boxes to indicate specific a uipment inspected/serviced: Tank ID: 87 Tank ID: 91 ® In-Tank Gauging Probe. Model: MAG 1 ® In-Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 303 ® Annular Space or Vault Sensor. Model: 303 ® Piping Sump/Trench Sensor(s). Model: 208/304 ® Piping Sump/Trench Sensor(s). Model: 208/ 304 ® Fill Sump Sensor(s). Model: 208/ 304 ® Fill Sump Sensor(s). Model: 208/ 304 ❑ 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). Tank ID: DIESEL TanklD: ® In-Tank Gauging Probe. Model: MAG 1 ❑ In-Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 303 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump/Trench Sensor(s). Model: 208/304 ❑ Piping Sump/Trench Sensor(s). Model: ® Fill Sump Sensor(s). Model: 2081 304 ❑ 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). Dispenser ID: 1-2 Dispenser ID: 3-4 ® Dispenser Containment Sensor(s). Model: 208/304 ® Dispenser Containment Sensor(s). Model: 208/304 ® 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: 2081304 ® Dispenser Containment Sensor(s). Model: 208/304 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: VENT BOX Dispenser ID: ❑Dispenser Containment ® Dispenser Containment Sensor(s). Model: 208/304 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): FELIX RAMIREZ Signature: , Certification No.. 5273934-UT License No: 08-1740 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113