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Appendix VI r 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 o�egulations This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be prepared for jE/ `P'r E each monitoring system control panel by the technician who performs the work.A copy of this form must be provided to the tank system �,/ ,yS J1 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. f/ed� A. General Information JUIq V I Facility A B C FOOD MART Bldg. No.: 2 0 2012 N.— Site nr1r1rasc713 N. ELDORADO City: STOCKTON Zip: Facility Contact Contact Phone No.: ( ) PERa,r,ENTAL H o.,...,..,. ER EALT� Make/Model of Monitoring VEEDER ROOT TLS-350 Date of Testing/Servicing: x/25/2012 VICES B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/seryiced: Tank ID: 87 Tank Size: Tank ID: Tank Size: In-Tank Gauging Probe. Model: MAG 1 E In-Tank Gauging Probe. Model: 9 9 ❑ Annular Space or Vault Sensor. Model: 302 E Annular Space or Vault Sensor. Model: E Piping Sump/Trench Sensor(s). Model: 208 E Piping Sump/Trench Sensor(s). Model: E Fill Sump Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: I ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: E 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 Size: Tank ID: 91 Tank Size: E In-Tank Gauging Probe. Model: MAG I E In-Tank Gauging Probe. Model: MAG I E Annular Space or Vault Sensor. Model: 302 E Annular Space or Vault Sensor. Model: SAME TANK ® Piping Sump/Trench Sensor(s). Model: 208 E Piping Sump/Trench Sensor(s). Model: 208 Fill Sump Sensor(s). Model: 208 E Fill Sump Sensor(s). Model: 208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: PLLD E 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). (:1Other(specify equipment type and model in Section E on Page 2). i Dispenser ID: 1/2 Dispenser ID: 3/4 ® Dispenser Containment Sensor(s). Model: 208 E Dispenser Containment Sensor(s). Model: 208 E Shear Valve(s). E 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 E Dispenser Containment Sensor(s). Model: 208 E Dispenser Containment Sensor(s). Model: 208 E Shear Valve(s). E Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s), Dispenser ID: 9/10 Dispenser ID: 11/12 E Dispenser Containment Sensor(s). Model: 208 E Dispenser Containment Sensor(s). Model: 208 0 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): E System set-up E 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" STREET GALT,CA 95632 Date of Testing/Servicing: 4I25/12 Monitoring System Certification Page 1 of 4 2/21/07