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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 Code of Regulations r This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be prepared for p I `;0 1 � each monitoring system control panel by the technician who performs the work.A copy of this form must be provided to the tank system ry z 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. A. General Information ;a Facility �I Q, k*; NnMA. COUNTRY CLUB 76 Bldg.No.: ;�C.. � °' z Site Address: 2575 COUNTRY CLUB City: STOCKTON CA Zip: Facility Contact Person: Contact Phone No.: ( ) e Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 1/25/2010 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. Model: MAG 1 ® In-Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 420 ® Annular Space or Vault Sensor. Model: 420 ® Piping Sump/Trench Sensogs). Model: 208 and 304 Brine ® Piping Sump/Trench Sensogs). Model: 208 and 304 Brine ® Fill Sump Sensor(s). Model: 208 and 304 Brine ® Fill Sump Sensor(s). Model: 208 and 304 Brine ® Mechanical Line Leak Detector. Model: LD-2000 ® Mechanical Line Leak Detector. Model: RED JACKET ❑ 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 ID: ® In-Tank Gauging Probe. Model: MAGI ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: SPLIT W 91 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump/Trench Sensor(s). Model: 208 and 304 Brine ❑ Piping Sump/Trench Sensor(s). Model: ® Fill Sump Sensor(s). Model: 208 and 304 Brine ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: RED JACKET ❑ Mechanical Line Leak Detector. Model: ❑ 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). Dispenser ID: 1-2 DispenserlD: 7-8 ® Dispenser Containment Sensor(s). Model: 208 ALSO 304 BRINE ® Dispenser Containment Sensor(s). Model: 20 ALSO 304 BRINE 8 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 3-4 DispenserlD: 9-10 ® Dispenser Containment Sensogs). Model: 208 ALSO 304 BRINE ® Dispenser Containment Sensor(s). Model: 208 ALSO 304 BRINE ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Floats)and Chain(s). Dispenser ID: 5-6 Dispenser ID: VENT SUMP ®Dispenser Containment ® Dispenser Containment Sensor(s). Model: 208 ALSO 304 BRINE Sensor(s). Model: 208 ALSO 304 BRINE ® Shear Valve(s). ❑Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). .lf 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 Pian 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): DAVE WINKLER Signature: �_.__� Certification No.: 5263373-UT License No: 08-1739 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 2 STREET GALT,CA 95632 Date of Testing/Servicing: 1-25-10 Monitoring System Certification Page 1 of 4 2/21/07