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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 This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for 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 form to the local agency regulating UST systems within 30 days of test date. A. General information Facility MEMORIAL HOSPITAL Bldg. No.: N.—LODI Site975 S. FAIRMONT AVE Cit LODI zip: 95240 Y' p' Address• Facility Contact Person: RANDY Contact Phone No.: ( ) Make/Model of Monitoring System: Veeder Root TLS -350, Auto -Stile jrl Date of Testing/Servicing: 10/11/2011 B. Inventory of Equipment Tested/Certified Check the aeeroeriate boxes to indicates ecific a ui ment Ins ectad/serviced: Tank ID: Tank Size: Tank ID: Tank Size: ® In -Tank Gauging Probe. Model: ® In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: ® Annular Space or Vault Sensor. Model: ® Piping Sump / Trench Sensor(s). Model: ® Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ 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). Tank ID: Old Diesel Tank Size: 5 K Tank ID: New Diesel Tank Size: 20 K ® In -Tank Gauging Probe. Model: MAG ® In -Tank Gauging Probe. Model: MAG 7 ® Annular Space or Vault Sensor. Model: 301 ® Annular Space or Vault Sensor. Model: 303 ® Piping Sump / Trench Sensor(s). Model: 302 ® Piping Sump / Trench Sensor(s). Model: 112 ❑ Fill Sump Sensor(s). Model: ® Fill Sump Sensor(s). Model: 112 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® 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). Dispenser ID: REMOTE FILL SUMP Dispenser ID: ® Dispenser Containment Sensogs). Model: 112 ® Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: TRANSITION SUMP Dispenser ID: ® Dispenser Containment Sensor(s). Model 1 1 1 ® Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: VENT SUMP Dispenser ID: ® Dispenser Containment ® Dispenser Containment Sensor(s). Model: 111 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 ® 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 Testi ng/Servicing: 10-11-11 Monitoring System Certification Page 1 of 4 2/21/07