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1 J Appendix VI JUN MONITORING SYSTEM CERTIFICATION 1 For Use By All Jurisdictions Within the State of CaliforniaSIR Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of tWERV7CS rAL F� 1T6�This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be pr each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system E 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: Site Address: Facility Contact Person: MONTEREY FUELING SINCLAIR Bldg. No.: 1001 E YOSEMITE AVE City: MANTECA CA Contact Phone No.: Zip: Make/Model of Monitoring System: GILBARCO EMC Date of Testing/Servicing: 1/29/2016 B. Inventory of Equipment Tested/Certified Check the aonrooriate boxes to indicate specific eauioment inspected/serviced: Tank ID: -87 Tank Size: Tank ID: 91 Tank Size: ® In -Tank Gauging Probe. Model: MAGI ❑ in -Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 409 ® Annular Space or Vault Sensor. Model: 409 ® Piping Sump / Trench Sensor(s). Model: 208 ® Piping Sump / Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model. ® Mechanical Line Leak Detector. Model: 99LD 2000 ® Mechanical Line Leak Detector. Model: 99LD 2000 ❑ 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: DIE Tank Size: Tank ID: Tank Size: ® In -Tank Gauging Probe. Model: MAG 1 ❑ In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 409 SPLIT W ❑ Annular Space or Vault Sensor. Model: ® Piping Sump / Trench Sensor(s). Model: 208 ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: 99LD 2000 ❑ 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). Dispenser ID: 1-2 Dispenser ID: 7-8 ❑ Dispenser Containment Sensor(s). Model: ❑ 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: 3-4 Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ® 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: 5-6 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). "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 Piot Pian 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): David Winkler Signature: Certification No.: 5263373 -UT License No: 08-1739 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0112 Testing Company Address: 416 2nd STREET GALT, CA 95632 Date of Testing/Servicing: 1-29-2016 Monitoring System Certification Page 1 of 4 2/21/07