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• Appendix VI MONITORING SYSTEM CERTIFICATION Vp`0 9 2017 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 ^ 1 This form must be used to document testing and servicing of monitoring equipment. A separate certification or report SN VIIi��R�I�ENTAL H EALTH each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tanTI V i E NT owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days ofsl6Lr ri1 A. General Information Facility Name: Site Address: EL DORADO FOOD MART - SHELL 2320 NORTH EL DORADO BLVD City: STOCKTON Facility Contact Person: BOB Bldg. No.: Zip: 95204 Contact Phone No.: (209) 994-4400 Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 212112017 B. Inventory of Equipment Tested/Certified Check the avj3ropriate boxes to indicatespecific equipment ins ected/serviced: Tank ID: 87 Tank ID: 91 N In -Tank Gauging Probe. Model: MAG 1 ® In -Tank Gauging Probe. Model: MAG 1 N Annular Space or Vault Sensor. Model: 302 ® Annular Space or Vault Sensor. Model: 302 N Piping Sump / Trench Sensor(s). Model: 352 ® Piping Sump / Trench Sensor(s). Model: 352 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: N Electronic Line Leak Detector. Model: PLLD ® Electronic Line Leak Detector. Model: PLLD N 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 ID: NA ® In -Tank Gauging Probe. Model: MAG 1 ❑ In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 302 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump / Trench Sensor(s). Model: 352 ❑ 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: PLLD ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: FLAPPER ❑ 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: 3-4 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: N Shear Valve(s). N Shear Valve(s). N Dispenser Containment Float(s) and Chain(s). N 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: N Shear Valve(s). N Shear Valve(s). N Dispenser Containment Float(s) and Chain(s). N 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. 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): N System set-up N Alarm history report Technician Name (print): FELIX RAMIREZ Signature: _d� Certification No.: B34976 License No: 5273934 -UT 08-1740 OTTL Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 Testing Company Address: 4162 nd STREET GALT, CA 95632 Date of Testing/Servicing: 02-21-17 Monitoring System Certification Page 1 of 4 2/21/07