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Parkwood Gas& Food 2098888157 P.19 CEIVED Appendix VI MONITORING SYSTEM CERTIFICATION J Ul L 2 5 20 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 Codi jP9yj! cor This form must be used to document testing and servicing of monitoring equipment.A separate certification or report m 4"W"I"W"o,"k RTi`%!ENT each monitoring system control panel by the technician who performs the work.A copy of this form must be provided to t1Kdt6hk�syitiir1 ownerjoperator-The ownertoperator must submit a copy of this form to the local agency regulating LIST systems within 30 days of test date. A. General Information Facility Name: TIWANA GAS&FOOD Bldg.No.: Site Address: 1210 E HAMMER LANE City. STOCKTON Zip: 95213 Facility Contact Person: PAUL Contact Phone No.: (209)477-3111 Make/Mcdel of Monitoring System: VEDDER ROOT TLS-360 Date of Testing/Servicing: 61812015 B. Inventory of Equipment Tested/Certified Check thea ropriate boxes to indicate seeeffic equipmerd inspected/serviced: Tank ID: 87 Tank Size: Tank ID: 89 Tank Size: In-Tank Gauging Probe. Model: MAG-1 0 in-Tank Gauging Probe. Model: MAG-1 Annular Space or Vault Sensor. Model: 420 0 Annular Space or Vault Sensor. Model. 420 19 Piping Sump/Trench Sensor(s). Model: 208 9 Piping Sump I Trench Sensor(s). Model: 208 E3 Fill Sump Sensor(s). -Model: Ej ft Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: RJ 1 16-056 CKI Mechanical Line Leak Detector. Model: RJ 116-056 0 Electronic Line Leak Detector. Model: C3 Electronic Line Leak Detector. Model: C9 Tank Overfill I High-Level Sensor. Model: 001 0 Tank Overfill I High-Level Sensor. Mcidel,. 001 [I Other(specify equipment type and model in Section E on Page 2). 0 Other(specify equipment type and model in Section E on Page 2). Tank ID: 91 Tank Size: Tank ID: Tank Size: • In-Tank Gauging Probe Model: MAG-1 [I In-Tank Gauging Probe. Model: • Annular Space or Vault Sensor. Model: 420 171 Annular Space or Vault Sensor. Model: I Piping Sump I Trench Sensor(s). Model: 208 [3 Piping Sump!Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: 0 Fill Sump Seri Model: Mechanical Line Leak Detector. Model: RJ 116-056 C Mechanical Line Leak Detector. Model: Electronic Line Leak Detector- Model: 0 Electronic Line Leak Detector. Model: Tank Overfill I High-Level Sensor. Model: ED Tank Overfill/High-Level Sensor. Model: 0 Other(specify equipment type and model in Section E on Page 2). [1 other(specify equipmenttype and model in Section E an Page 2). Dispenser ID: 1/2 Dispenser ID: 314 ❑ Dispenser Containment Sensor(s). Model: El Dispenser Containment Sensor(s). Model: ShearValve(s). 0 ShearValve(s). 19 Dispenser Containment Float(s)and Chain(s). 0 Dispenser Containment Float(s)and Chain(s). Dispenser ID: 616 Dispenser ID: 718 ❑ Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model: ShearValve(3). 0 Shear Valve(s). Dispenser Containment Float(s)and Chain(s). 0 Dispenser Containment Ficat(s)and Chain(s). DispenserID! Dispenser ID: [j Dispenser Containment 0 Dispenser Containment Sensor(s). Model: Seri Model: El ShearValve(s). 0 Shear Valve(s). 0 Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s)- 111'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 inspectediserviced 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 afi thag apply) System set-up 0 Alarm history report Technician Name(print): Ed Steams Signature: Certification No.; A31040 License No: Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address:— Z1'62STREET GALT,CA 95632 Date of TestingiServicing: 6/6115 Monitoring System Certification Page I of 4 2121/07 Received Time Jul, 25. 2018 10 :46AM No. 3918