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t 2 Appendix VI MONITORING SYSTEM CERTIFICATION P,P 6 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 This form must be used to document testing and Servicing of monitoring equipment.A separate certification or report $t b e rrk- ;y,°F) each monitoring system control panel by the technician who performs the work.A copy of this form must be pro , i, Owner/operator.The owner/operator must submit a Copy of this form to the local agency regulating UST systems within 30 dal Ok% 1�-i'v"10ENT A General Information: Facility Name: UNITED PACIFIC #5447 Bldg,No.: Site Address: 1469 E HAMMER LANE City: STOCKTON CA Zip: 95210 Facility Contact Person: Contact Phone No.: ( ) Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 8/31/2017 B. Inventory of Equipment Tested/Certified Check thea opropriate boxes to indicatespecific equipment ins ectedlserviced: Fo nk ID: 87 Tank Size: Tank ID: 91 Tank Size: In-Tank Gauging Probe Model: MAG 1 N In-Tank Gauging Probe. Model: MAG 1 Annular Spare or Vault Sensor Model: 409 N Annular Space or Vault Sensor. Model: 409 Piping Sump/Trench Sensor(s). Model: 208 N Piping Sump/Trench Sensor(s), Model: 208 ❑ Fill Sump Sensor(s), Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector Model: 99LD 2000 N Mechanical Line Leak Detector. Model: 99LD 2000 ❑ 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: DIE Tank Size: Tank ID: 89 Tank Size: ® In-Tank Gauging Probe, Model: MAG 1 N In-Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor, Model: 409 N Annular Space or Vault Sensor Model: 409 ® Piping Sump/Trench Sensor(s). Model: 208 N Piping Sump/Trench Sensor(s), Model. 208 ❑ Fill Sump Sensor(s)_ Model: ❑ Fill Sump Sensor(s). Model: N Mechanical Line Leak Detector Model: 99LD 2000 N Mechanical Line Leak Detector. Model: 99LD 2000 ❑ Electronic Line Leak Detector Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor, Modem. ❑ 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: 7-8 N Dispenser Containment Sensor(s). Model: 406 N Dispenser Containment Sensor(s). Model: 406 N Shear Valve(s) N Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 3-4 DispenserlD: 9-10 N Dispenser Containment Sensor(s), Model: 406 ® Dispenser Containment Sensor(s), Model: 001 N Shear Valve(s), N Shear Valve(s) ❑ Dispenser Containment Float(s)and Chain(s) ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5-6 Dispenser ID: ® Dispenser Containment Sensor(s). Model: 406 N Dispenser Containment Sensor(s), Model: N Shear Valve(s), N 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 ®Alarm history report Technician Name(print): David Winkler Signature: _ Certification No.: 5263373-UT License No: 08-1739 Testing Company Name: AFFORDA-TEST Phone No, (209)744-0112 Testing Company Address: 416 2 STREET GALT,CA 96532 Date of Testing/Servicing: 8-31-17 Monitoring System Certification Page 1 of 4 2/21/07