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r r op_ . a REC'CjVrn Appendix VI FEB MONITORING SYSTEM CERTIFICATION ��/ 1 72016 For Use By All Jurisdictions Within the State of California Chapter 16 Division 3 Title 23, California C A41 -r R,IS Authority Cited: Chapter 6.7, Health and Safety Code; p _ This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepa VICCS� LrF{ 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 cropy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: COUNTRY CLUB Valero Bldg. No.: Site Address: 2575 COUNTYRY CLUB City: STOCK 'ON Zip: 95204 Facility Contact Person: NIC Contact Phone No.: (209) 932-1307 Make(Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 1-29.2016 B. Inventory of Equipment Tested/Certtfied Check the appMrialte boxes to Indicate s ific ui ent i servic�i: Tank ID: 87 Tank ID: 91 ® In -Tank Gauging Probe. Model: MAGI ® In -Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 420 ®Annular Space or Vault Sensor. Model: 420 ® Piping Sump / Trench Sensor(s). Model: 208 ® Piping Sump /Trench Sensor(s). Model: 208 ® Fill Sump Sensor(s). Model: 208 ® Fill Sump Sensor(s). Model: 208 ® Mechanical Line Leak Detector. Model: RED JACKET ® Mechanical Line Leak Detector. Model: LD 2000 Madel: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. ® Tank Overfill / High -Level Sensor. Model: 90% ® Tank Overfill / High -Level Sensor. Model: 90% ❑ 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: 19 In -Tank Gauging Probe. Model: MAG 1 ❑ In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 420 SPLIT W 91 ❑ Annular Space or Vault Sensor. Model: JR Piping Sump / Trench Sensor(s). Madel: 208 ❑ Piping Sump / Trench Sensor(s). Model: I@ Fill Sump Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Madel: ® Mechanical Line Leak Detector. Model: RED JACKET ❑Mechanical Line Leak Detector. Model: n❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: 90% ❑ 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 Senors). Model: 208 ® Dispenser Containment Sensor(s). Model: 208 ® 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 Model: 208 ® Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). ® Shear Valve(s). ® Shear Valve(s). [3 Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 9-10 Dispenser ID: VENT SUMP ® Dispenser Containment ® Dispenser Containment Sensor(s). Model: 208 Sensor(s). Model: 208 ❑ 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 inspectedlserviced in accordance with the manufacturers' checklists) necessary to verify that this information is correct guidelines. Attached to this Certification is information (e.g. manufacturers' Plan the layout of monitoring equipment For any equipment capable of generating such reports, i have also attached a and a Plot showing copy of the report; (check all that apply): ® System set-up ® Alarm history report Technician Name (print): DAVE WINKLER Signature: Certification No.: 5273934 -UT License No: 08-1740 Phone No. (209) 744-0113 Testing Company Name: AFFORDA-TEST Testing Company Address: 416 2n° STREET GALT CA 95632 Date of Testing/Servicing: 1-29-16 2/21/07 Monitoring System Certification Page 1 of 4 E