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` Appendix VI WEIVE® MONITORING SYSTEM CERTIFICATION t1�T 0 4 X011 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 ENVIRGNMEN-AL HEALTH. This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be prepared forPERI1 7SEFi't/ICiECJ 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 forth to the local agency regulating UST systems within 30 days of test date. A. General information Facility 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 appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: 87 Tank ID: 91 ® in-Tank Gauging Probe. Nlodei: MAG 1 0 IrrTar,k Gauging Prubv. Mcdel: MAG 1 ® Annular Space or Vault Sensor. Model: 303 ® Annular Space or Vault Sensor. Model: 303 ® Piping Sump/Trench Sensor(s). Model: 2081304 ® Piping Sump/Trench Sensor(s). Model: 2081 304 ® Fill Sump Sensor(s). Model: 2081 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 Tank ID: ® 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: 208/ 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 1304 ® 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: 6-6 Dispenser ID: 7-8 ® Dispenser Containment Sensor(s). Model: 208/304 ® Dispenser Containment Sensor(s). Model: 208/304 ® Shear Valve(s). ® Shear Valve(s). L1—:1 Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Co tairmcnt Flcst(s)and C`ain(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 El Alarm history report Technician Name(print): FELIX RAMIREZ Signature: fir ` Certification No.: 5273934-UT License No 08-1740 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 2 STREET GALT,CA 95632 Date of Testing/Servicing: __98-23-11 _ Monitoring System Certification Page 1 of 4 2/21/07 AJC �=fit