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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 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 Kinma. JAMAR SVC Bldg . No. : Site Arldraccm 4075 EAST MAIN STREET City: STOCKTON Zip: 95205 Facility Contact Pp.r.cnn4 JASON Contact Phone No. : (209) 462-4685 Make/Model of Monitoring System : VEEDER ROOT TLS 350 Date of Testing/Servicing : 5117118 B . Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment ins ected/serviced : Tank ID : 87 Tank ID : 91 E In-Tank Gauging Probe . Model : MAG 1 E In-Tank Gauging Probe . Model: MAG 1 E Annular Space or Vault Sensor. Model : 409 E Annular Space or Vault Sensor. Model : SPILT 187 E Piping Sump / Trench Sensor(s) . Model : 208 E Piping Sump / Trench Sensor(s) . Model : 208 ❑ Fill Sump Sensor(s) . Model : ❑ Fill Sump Sensor(s) . Model : E Mechanical Line Leak Detector. Model : PE PETRO E Mechanical Line Leak Detector. Model: 99 LD 2000 ❑ Electronic Line Leak Detector. Model : ❑ Electronic Line Leak Detector. Model : E Tank Overfill / High-Level Sensor. Model : FLAPPER E Tank Overfill / High- Level Sensor. Model : FLAPPER El (specify equipment type and model in Section E on Page 2) . [3 Other (specify equipment type and model in Section E on Page 2) . Tank ID : NA Tank ID : NA ❑ 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 : 1 -2 Dispenser ID : 34 ❑ Dispenser Containment Sensor(s) . Model : ❑ Dispenser Containment Sensor(s) , Model: E Shear Valve(s) . E Shear Valve(s) . E Dispenser Containment Float(s) and Chain (s) . E Dispenser Containment Float(s) and Chain (s) . Dispenser ID : 5-6 Dispenser ID : 7-8 ❑ Dispenser Containment Sensor(s) . Model : ❑ Dispenser Containment Sensor(s) . Model : E Shear Valve(s) . E Shear Valve(s) . E Dispenser Containment Float(s) and Chain (s) . E Dispenser Containment Float(s) and Chain (s) . Dispenser ID : NA Dispenser ID : NA ❑ 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 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) : E System set- up ® Alarm history report Technician Name (print) : FELIX RAMIREZ Signature: Certification No. : B34976 License No: 8883072- UT 08- 1740 OTTL Testing Company Name: AFFORDA-TEST Phone No . (209) 744-0113 Testing Company Address : 416 2nd STREET GALT CA 95632 Date of Testing/Servicing : 05- 17- 18 Monitoring System Certification Page 1 of 4 2/21 /07