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0 Appendix VI 0 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of Cal'Ifomis 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 Name: LODI MEMORIAL HOSPITAL Bldg.No.: Site Address: 9755 S FAIRMONT City: LODI Zip: Facility Contact Person: RANDY Contact Phone No.: (209)339.7657 Make/Model of Monitoring System: VEEDER ROOT TLS350 Date of Testing/Servicing: 10-09-13 B. Inventory of Equipment Tested/Certified Check the a ro rlate'-boxes to Indicate specific ui ent ins— Tank ris servic�l: FID: EL Tank ID: g Probe. Model: MAG 1 ❑ in-Tank Gauging Probe. Model: or Vault Sensor. Model: 303 ❑ Annular Space or Vault Sensor. Model: Trench Sensor(s). Model: MAG SENSOR ❑ Piping Sump/Trench Sensor(s). Model: ® Fill Sump Sensor(s). Model: MAG SENSOR [3Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model; ® 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 Simon E on Page 2). Tank Tank ID: ❑ 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(,). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: 13 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: [3 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: VENT SUMP 1 Dispenser ID: VENT SUMP 2 ® Dispenser Containment Sensor(s). Model: aAAG SENSOR ® Dispenser Containment Sensogs). Model: MAG SENSOR ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: FILL SUMP Dispenser ID: ® Dispenser Containment Sensogs). Model: MAG SENSOR ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). [3 Dispenser Containment Float(s)and Chain(s). [3 Dispenser Containment Float(s)and Chain(,). Dispenser ID: Dispenser ID: ❑Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: Sensor(s). Model: ❑ Shear Valve(s). ❑Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). .t the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility. C.Certification-1 certify that the equipment Identified In this document was Inspectediserviced 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 aU that apply): ®System set-up ®Alarm history report Technician Name(print): FELIX RAMIREZ Signature: 'Z`�� Certification No.: 5273934-UT License No: 08-1740 Testing Company Name: AFFORDA-TEST Phone No. (209)744 0113 Testing Company Address: 416 2 STREET GALT CA 95632 Date of Testing/Servicing: 10 10-12 Monitoring System Certification Page 1 of 4 2/21/07 D. Results of TestinglServicing