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0 Appendix V1 MONITORING SYSTEM CERTIFICATION Oh EffT17=,CV1E,Tn=,I VE D 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 dY k4tia@obi 814 This form must be used to document testing and servicing of monitoring equipment.A separate certification or rt t b 'red for a r r� s r each monitoring system control panel by the technician who performs the work.A copy of this form must be pr 61WIJ� UA I HEALTH owner/operator.The owner/operator must submit a copy of this form to the local agency regulating LIST systems within 0 dayj-of�,Qi'a&!e: N T A. General Information Facility Name: LODI MEMORIAL HOSPITAL Bldg.No.: Site Address: 9756 S FAIRMONT City: LODI Zip: Facility Contact Person: RANDY Contact Phone No.: (209)339-7667 Make/Model of Monitoring System: VEEDER ROOT TLS360 Date of Testing/Servicing: 10-09-14 B. Inventory of Equipment Tested/Certified Check thea ro r(ate boxes to indicates ecific Mipment ins pe diserviced: Tank ID: DIESEL Tank ID: • In-Tank Gauging Probe. Model: MAG 1 [1 In-Tank Gauging Probe. Model: • Annular Space or Vault Sensor. Model: 303 0 Annular Space or Vault Sensor. Model: • Piping Sump/Trench Sensor(s). Model: MAG SENSOR [I Piping Sump/Trench Sensor(s), Model: • Fill Sump Sensor(s). Model: MAG SENSOR C1 Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: PLLD 171 Electronic Line Leak Detector. Model: El Tank Overfill/High-Level Sensor. Model: [I Tank Overfill/High-Level Sensor. Model: [I Other(specify equipment type and model in Section E on Page 2). [1 Other(specify equipment type and model in Section E on Page 2). Tank ID: Tank ID: [I In-Tank Gauging Probe. Model: C1 In-Tank Gauging Probe. Model: [] Annular Space or Vault Sensor. Model: El Annular Space or Vault Sensor. Model: 0 Piping Sump/Trench Sensor(s). Model: [I Piping Sump/Trench Sensor(s). Model: [I Fill Sump Sensor(s). Model: [I Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: Cl Mechanical Line Leak Detector. Model: C] Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: E] Tank Overfill/High-Level Sensor. Model: [I Tank Overfill/High-Level Sensor. Model: [I Other(specify equipment type and model in Section E on Page 2). [1 Other(specify equipment type and model in Section E on Page 2). Dispenser ID: VENT SUMP 1 Dispenser ID: VENT SUMP 2 * Dispenser Containment Sensor(s). Model: MAG SENSOR 0 Dispenser Containment Sensor(s). Model: MAG SENSOR * Shear Valve(s). El Shear Valve(s). [I Dispenser Containment Float(s)and Chain(s). Ej Dispenser Containment Float(s)and Chain(s). Dispenser ID:_FILL SUMP Dispenser ID: 0 Dispenser Containment Sensor(s). Model: MAG SENSOR 0 Dispenser Containment Sensor(s). Model: [I Shear Valve(s). [I Shear Valve(s). E] Dispenser Containment Float(s)and Chain(s). E] Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: El Dispenser Containment 0 Dispenser Containment Sensor(s). Model: Sensor(s). Model: [I Shear Valve(s). El Shear Valve(s). [] Dispenser Containment Float(s)and Chain(s). E:]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): Z System set-up Z Alarm history report Technician Name(print): FELIX RAMIREZ Signature: Certification No.: 5273934-UT License No: 08-1740 Testing Company Name: -AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416�ZSTREET GALT,CA 95632 _ Date of Testing/Servicing: 10-10-14 Monitoring System Certification Page 1 of 4 2/21/07