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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 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 ownerloperator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. General Information Faculty TRACY VALERO Nemo• --..-.—. Site Address; 2375 N. TRACY BLVD. city: TRACY Facility Contact Parsnnr Contact Phone No.: Make/Model of Monitoring system: VEEDER ROOT TLS -350 Bldg. No.: B. Inventory of Equipment Tested/Certified f-&. 11 N.n"g..n.. An fa 1-na fn inr i fa anarifin a iAnmant inananfarilsarvicart' Zip: 95377 Date of Testing/Servicing: 9/5/2013 Tank ID: 87 Tank Size: Tank ID: Tank Size: ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: * Annular Space or Vault Sensor, Model: 407 ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sonsor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line teak Detector. Model: O 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). O Other (specify equipment type and model in Section E on Page 2). Tank ID: DIE Tank Size: Tank ID: 91 Tank Size: O In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: i0 Annular Space or Vault Sensor. Model: 407 0 Annular Space or Vault Sensor. Model: 407 ❑ Piping Sump / Trench Sensor(s). Model ❑ Piping Sump/ Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: O Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: O 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). DispenserlD: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). O Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 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: 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. incluse Intormation ter every ianK ana aispenser at the racnny. 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 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): ZANE NIMMO Certification No.: A26446 ___ Testing Company Name: AFFORDA-TEST Testing Company Address: 416 2 STREET GALT, CA 95632 Signature: > ..-...,.... , License No _ 04-1676 _ ___-_ Phone No. ,_(2092 744-01 1 3 Date of Testing/Servicing: 9/5/13 Monitoring System Certification Page 1 of 4 2/21/07