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Appendix VI" MONITORING SYSTEM CERTIFICATION -- - For Uae By NI Jurisdictions Within the Stine of Califomill Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 18, division 3, Tins 23, California Code of Regulalf This fort must used to document testing and servicing of monitoting equipment A $operate ce WwAlian or report must be prepared for ends monitoring system control pend by the technician who performs the Work, A copy of this form mutt be pro+Aded to the tank system ownerloperttar. The ownenoperodor must submit a copy of this form to the local alloncy roguli tlng UST Systems within 30 days of test date A. Ganierallhlormation Facft Name:. Et3f3At.ON RUNI MART Hidg. No.: � -- SNe ,,ddraes: 141'r H YOUMtTfi Gity: E$CALON ZP- tra320 Fadibr Contact Person: BU_t. Contact Phone No,: (209 ss84d44 Make/Moae) of Monitoling System: AUVOS n)(JR Z Date of TestinglSeMcIrIg: s B. Inventory of Equipment Tested/Certified Cheek the oppropikilte boxes to indicates elfio equipment I ectediserviced: J Tank In: 87 TanklD: 91 I& (r►Tarrk GaugYtg Pmba. Model: MAG ® In-T4nk Gauging Probe. Modd: tLf�ca ® Mnuler Space crVa ASensor. Model: UTA - ❑ Annular space or Vault Sensor. Model; ULS 10 Piping Sump I Trench Sensvr(s). Mom: ULS ® Piping Sump/ Trench Sensor(a). mel: ULt3 ❑ Fill Sump sensor(s). Model: Gil Fill Sump Sehsor(s). Model: IN Mechanical Line Leak detecWr. Model: RED JACKET 01 Mechanical Line Leak Detector, Model: RED JACKET J9 Electronic Une Leo* Detector. Model: ❑ Electronic Line Leak Detector. Model: 0 Tank Overfill t High -Lend Sensor. Model: FLAPPER ® 'rank Overfill / High -Level Sensor. Model: FLAPPER mode! in Flection E ort Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). ❑ other (specify equipmentt"and TanklD: TanklD: ❑ in -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe, Model: a Annular Spact or Vautt Sensor. Model: ❑ Annular Spawc or Vault Sensor. Model: ❑ Piping Sump t Trench Seneor(s). Model: ❑ Piping Sump I Trench Sanaor(s). Model: ❑FBI Sump Sensor(s). Model: [3FiltSUMP Senaor(s), Model: ❑ Mechanical Lime Leak Detector. Model, ❑ Mechankol Line Leak dettctor. Model! 14 Elect line Leak Detector. Madel: Q Electronic Line teak Detector'. Modal: ❑ Tank Overnit r High -Level Sensor. Model: ❑ Other(spectry equipment type And model in Seci)en E on Page 2). ❑ Tam Overfill / Hlgh-Levd Sensor. Model: ❑ Other (spectry equipment type and hiodal in Secdort E an Page 2)_ Dispenser ID: 1-2 Dlsponser ID: 3-4 ® Dispenser Containment Sanaor(s). Model: ULp ® DMpetsar Containment Sensor(sj Model: ULS ®Stress Valve($). Shear valve(s). Containment Flange) 411d ChWn(a). ❑ Dispenser Containment Flost(s) and Chain(s). ❑ Dispenser Dispenser ID: 7-8 Dispenser' IA: tib Contaitmerr samr(s)• Madet: ULS ® Dispenser Containment sensor(s). Model: ULS ® Dispenser 0 ShearVatva(s), ,® Shaarvaiive(s) Flast(s) and Chain(a} ❑ Dispenser Containment Float(a) and Chain(s). 11 Dispenser Containment Dispenser ID. DbP * ID p Dispenser containment [3, Dispersos Gottta6nmerrt Se,nsor(sl. Model Sensor(s). Anodal: Shear Ci Valve(s). ❑ Stress vaive(s). ❑ Dispenser Containment Float(s) and Chain($}. [31 Dispenser Cchtninment Flosgs) and Chain(a)• this form. Indude infonnekon for every tank and dispenser at the facility. •If the fadfity contslns more tanks or dispensers. copy t=. Csrtffieatlon - t certify that the batriprent s Infofled in this d cerns" VMS msnMlectarers checkHatsl nececedssary to Verify thatthisn accordafte with einfforrmation M cermet (e.g. Inringe to this Cerout gulddines Attached 1fie tryout of monitoring egmpdnent For any equipment capable or generating such reports, i have also at- a'ads of im n ul srrd a Piot Ain sh4vviny copy of the ftport: (aback au OW s0/*): ❑ System aet.up ❑ Alarm hlW y report Technician Name (print): FELIX RAMIREZ Signature: ft -in -1 CertJfication No.: 52739 UT - - License No: 08-1740 Phone No. 209 744-0113 Testing Company Name: AFFORDA-TEST `f'eaftng Company Address: 4162" STREET GALT CA 9 Date of Tes' /Servicing; 12-19 15 hr+g Mondoring Gntfficaiion Page i of 4 Syatem b` ; i