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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 phis 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 da A. General Information ENTAL HEALTH Facility LODI FOOD AND LIQUOR Bldg. No.: _ �' ICES ni�n,A Site Aririrpss 1225 K LOCKEFORD ST. City: LODI, CA Zip: 95240 Facility Contact Pprann PAUL Contact Phone No.: Make/Model of Monitoring System: INCON TS 1001 Date of Testing/Servicing: 11123/2010 B. Inventory of Equipment Tested/Certified Ckeci, the a ro Ante hnvec to Indicate specific enuinment inspected/serviced: .......... .. .., vp,.. vt.. .a.w .......... ................ �,.-�_..._ _ �. .--____ - -- - - Tank ID: Tank'Size: 10 K Tank ID: Tank Size: _87 ® In -Tank Gauging Probe. Model: MAG ❑ In -Tank Gauging Probe. Model: 0 Annular Space or Vault Sensor. Model: EIS ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ULS ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: 99 LD 2000 ❑ Mechanical Line Leak Detector. Model: EI Electronic Line Leak Detector. Model: 171Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model P ❑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: 91 Tank Size: 5 K 'i i; Tank ID: DIE Tank Size: 5 K ;I ® in -Tank Gauging Probe. Model: MAG in -Tank Gau i ® g'ng Probe. Model: MAG ® Annular Space or Vault Sensor. Model: EIS ® Annular Space or Vault Sensor. Model: SAME AS DIESEL ® Piping Sump / Trench Sensor(s). Model: ULS ® Piping Sump / Trench Sensor(s). Model: ULS fil ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: _ ® Mechanical Line Leak Detector. Model: STP MLD ® Mechanical Line Leak Detector. Model: 99 LD 2000 ii ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model ❑ Tank Overfill I 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: 3/4 Dispenser ID: 112 ❑ Dispenser Containment Sensor(s). Model: ULS ® Dispenser Containment Sensor(s). Model: ULS Z Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). I Dispenser ID: 5/6 Dispenser ID: 7/8 ® Dispenser Containment Sensor(s). Model: ULS ® Dispenser Containment Sensor(s), Model: ULS ® Shear Valve(s). ® Shear Valve(s). i� ED Dispenser Containment Float(s) and Chain(s). [I Dispenser Containment Float(s) and Chain(s). _ 1 Dispenser ID: Dispenser ID: ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: Sensor(s). Model: E4 Shear Valve(s). ® Shear Valve(s). L ❑ 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 A NIMMO Signature: Certification No.: A28446 License No: L0044-1676 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 Testing Company Address: 416 2 STREET GALT CA 95632 Date of Testing/Servicing: 11/23/10 Monitoring System Certification Page 1 of 4 2/21/07