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Appendix VI MONITORING SYSTEM CERTIFICATION F, 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 J, 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 g, 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. k4l, A. General Information �Y )v2go , Site Facilily STOCKTON AUTO CENTER--- CALIFORNIA CAR WASH Bldg. No.: ��&yg4�i�/ Address• 3434 E. HAMMER LN. City: STOCKTON Zip: 95212 T°1%��j Facility Contact Person, CHRIS B. Contact Phone No.: (209) 956-4040 Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 6/25/2009 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: 87 Tank ID: 91 ® In -Tank Gauging Probe. Model: MAG 1 ® in -Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 420 ® Annular Space or Vault Sensor. Model: 420 ® Piping Sump / Trench Sensor(s). Model: 208 ® Piping Sump / Trench Sensor(s). Model: 208 ® Fill Sump Sensor(s). Model: 208 ® Fill Sump Sensor(s). Model: 208 ® 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: ❑ 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 ID: N/A ® in -Tank Gauging Probe. Model: MAG 1 ❑ in -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: SAME TANK W/ 91 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump / Trench Sensor(s). Model: 208 ❑ Piping Sump / Trench Sensor(s). Model: ® Fill Sump Sensor(s). Model: 208 ❑ 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: ❑ 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: ® Dispenser Containment Sensor(s). Model: 208 ❑ 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: 208 ® 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: 208 Sensor(s). Model: ® Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). it the tacility 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 NIMMO Signature:- Certification No.: A28446 License Nd ' 04-1676 Testing Company Name: AFFORDA-TEST Phone No. X209) 744-0113 Testing Company Address: 416 2" STREET GALT CA 95632 Date of Testing/Servicing: _ 6/25/09 Monitoring System Certification Page 1 of 4 jSC 2/21/07