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Appendix VI RECEIVED MONITORING SYSTEM CERTIFICATION NOV 2016 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 Regulationsglpp HE p T This form must be used to document testing and servicing of monitoring equipment.A separate certification or repo TAA i-1 C/°1L! each monitoring system control panel by the technician who performs the work.A copy of this form must be provid a an s ste -r� -� owner/operator.The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days I A. General information Facility Name: SAN JOAQUIN COUNTY JAIL Bldg.No.: Site Address: 7000 MICHAEL CANLISS City: FRENCH CAMP Zip: 95231 Facility Contact Person: Contact Phone No.: (209)712-5931 Make/Model of Monitoring System: OPW Date of Testing/Servicing: 11/15/2016 B. Inventory of Equipment Tested/Certified Check the a ro riate boxes to indicates ecific a ui ment ins ectad/serviced: Tank ID: N.DIE Tank Size: Tank ID: S.DIE Tank Size: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: ® 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 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). Tank ID: Tank Size: Tank ID: Tank Size: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ 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 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: 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 Sensor(s). Model: ® Dispenser Containment Sensor(s). Model: ❑ Shear Vaive(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: ❑ Shearvaive(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 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): Ed Steams Signature: f - Certification No.: A31048 License No: Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 4162 nd STREET GALT,CA 95632 Date of Testing/Servicing: 11/15/16 Monitoring System Certification Pagel of 4 2/21/07