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Appe r dix VI MONITORING SYS M CERTIFICATION For Use By All Jurisdictions' ithin the State of California Authority Cited:Chapter 6.7,Health and Safety Code;.Chap 16,Division 3,Title 23,California Code of Iulatfons; , This form must be used to document testing and servicing of,monitoring equipmer separate certifigaikW or report must be prep Ar foC. each monitoring system control panel by the technician who performs the work.A x py of this form must be provided totw tank system.. owner/operator.The owner/operatormustsubmit a copy of this form to the locaL. lency regulating UST;�swttllsn 30 days of feet date' A General Information - Facility Name: P.. Tr-.A EXPRESS 76 Bldg-No.: Site Address: '-i� T City. MANTECA CA ?jp• Facillty.Comact BOBBY Cotrtelt�tloneNc: (?6I) �`'L 914 PPrQny Make/Model of Monitoring System: VEEDER ROOT Dv of Te 6-41-13 B., ,. •.:Iatiteliinty,of Equipmeifit< esfed/Ceriified; CheclEth :. o nate loxes to'Jndlcate spac@ilc:. . a �lfts servlCed: Tank ID 8x'; Tank ID:...91 ._.. _ ® In-Tank Gauging Probe. Model: MAG 1 ® In-Tank Gauging Probe. Model: ARMI ® Annular Space or Vault Sensor. Model: 420 ® Annular Space or Vault Sensor. Modek 420 ® PlP1ng.Sump./Trench:Sensor(s).. Modet,208 Piping Sump 6TI�e��0tr�s� Model r.r ❑ FiII Sump Sensor(s). Model:- r_ Fill Sur60$Wen&df{5)i� �r:; Ntodey .� 'T i ® Mechanical Une Leak Detector. -Model: -9914 2000 ®'MechanicaV�kine Lea.ttetei or. MOdeb LD 2000 - ❑ Electronic Line Leak Detector. Model: ❑Electronic Line-Leak+Detector. Model::• ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). Tank ID: DSL Tank 10: ® In-Tank Gauging Probe. Model: MAG 1 ❑ In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 420 ❑Annular Space or Vault Sensor. Model Piping Sump/Trench Sensor(s). Model: 208 ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor($). Model: ❑ FIII Sump Sensor(s). Model: ® Mechanical Une Leak Detector. Model: FXIV D ❑ Mechanical Une Leak Detector. Model: ❑ Electronic Une Leak Detector. ' ,del: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sens Model: ❑Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment typf a. �,..adel in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). Dispenser ID: 1-2 Dispenser ID: - ® Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Modelo ® Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chaln(s). Dispenser ID- 3.4 Dispenser-ID: ❑ Dispenser Containment Sensor(s). Model: ® Dispenser Containment Sensor(s). Model: ® ShearValve(s). ® ShearVaive(s). ® Dispenser Containment Floats)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dig M: Dispenser Containment ❑.Dispenser Containment Sensor(s). Model: Sensor(s). Model: D Shear Valve.(s). ®Shear VaWe(s). [I Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Floats)and Chain(s). 'If the facility contains more tanks or dispensers,copy this form. Include informatior J r every tank.and dispenser atthe facility. C.Certification-I ceMfy that the equipment Identified to this-document was Ins x Aed/serviced in accordance with the manufacturers'.. guidelines.Attached to this Certification is information(e.g:manufacturers' h klists)necessary to verify that this Information is correct and a Plot Plan stowing the layout of monttorin equipment.For any eqt capable of.generating such reports,I have also.attached a copy of the report;(check all that apply): 0 System set-up Mil 4 tiWary report Technician Name(print): DAVE WINKL..R Signature: _ ,/-'T�, cabon No.: 5263373-UT License No: 08-1739 eating Company Name: Ar F3 N.FEST Phone No. (209)7440113 Testing Company Address ' STREET GALT CA 95632 Date of Testing/Servicing: 19 48 Monitoring System Certlftcation Pag of 4 r • 2/21/07 JUL ..1 1 2014 ENVIRONMENTAL HEALTH DEPARTMENT