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0 HF-GEIVED Appendix VI FEB201 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California y Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code a a W BUYMENTAL This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepar6TtdrnC0 1 T 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 Name: Site Address: Facility Contact Person: EL DORADO SH 2320 EL DORADO Make/Model of Monitoring System: VEEDER ROOT TLS 350 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment ins Bldg. No.: City: STOCKTON Zip: 95204 Contact Phone No.: (209) 483-1311 Date of Testing/Servicing: 2-11-15 Tank ID: 87 Tank Size: 11627 ® In -Tank Gauging Probe. Tank ID: 91 Tank Size: 11627 ® In -Tank Gaugieg Probe. Model: MAG 1 Model: 352 ® In -Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 304 Model: PLLD ® Annular Space or Vault Sensor. Model: 304 ® Piping Sump/ Treed-ensor(s). Model: 352 ❑ Dispenser Conti anent Sensor(s). ® Piping Sump/ Trench Sensor(s). Model: 352 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® ShearValve(s). ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic t ine Leak Detector. Model: PLLD ® Electronic Line Leak Detector. Model: PLLD ® Tank Overfill / High -Level Sensor. Model: FLAPPER ® Tank Overfill / High -Level Sensor. Model: FLAPPER ❑ 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: 11627 ® In -Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 304 ® Piping Sump / Trench Sensor(s). Model: 352 ❑ Fill Su:rp Senssr(s). Model: ❑ Mechanical Line Leak Detector. Model: Electronic Line Le=k Detector. Model: PLLD ❑ Tank Oveifll /IHS `,-Level Sensor. Mor'^' rLAPPER ❑ Other (specify e- "-i-it'ype and mod l i, i SeCion E on Page 2). DispcnserID: '-2 ❑ Dispenser Conti anent Sensor(s). Model: ® Shear Valvels)_ 7 DI rnrs=r Cort nment Float(s) and Cha- (s). Dispns: '.D' `-5 ❑ Dispenser ,nta;nn,-nt Sensor(s). Model: ® ShearValve(s). Dispenser Containment Floatls) and Chain(s). Tank ID: Tank Size: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: 3-4 ❑ Dispenser Containment Sensor(s). Model: ® Shear Vaive(s). ® Dispenser Containment Float(s) and Chain(s). Dispenser ID: 7-8 ® Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ® Dispenser Containment Float(s) and Chain(s). Dispensnri0 _ _ Dispenser ID: ❑ Dispenser Containment ❑ Dispenser Conr n rt Sensor(s). Model: _ Sensor(s). Model: shearv7l,ets/_ ❑ ShearValve(s). D nenser cont :nt Floaus) and a 'r(s). ❑ Dispenser Containment Float(s) and Chain(s). fa d tanks or dispe vers, cnry tl � torr nclude information for every tank and dispenser at the facility. - I , , th t thr eouipment i 'entified in this document was inspected/serviced in accordance with the manufacturers' r-nldeli nes. Atter to th!s Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct ny the layout of rnor l orioq equipment. For any equipment capable of generating such reports, I have also attached a c .arra rA .d1 ih,a upl lo: ® System set-up ® Alarm history report ' iic -n r'e David Winkler Signature: G= "—ti^ -No.: 5253373 -UT License No: 08-1739 C�rnpa -ie AF CRDA-TEST Phone No. (209)744-0112 -.cripa , A' ress: 411 2"'S- SEE ,,LT, CA 1)5632 Date of Testing/Servicing: 2-11-15 '1onito,;,, s' =, "ertification Page 1 of 4 2/21/07