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Appendix V! ONITORiNG'SYSTEM CERTIFICATION For Use By All Jurisdictions Within the Stater of California Authority Cited: Chapter 6.7, Health and Safety Code!; Chapter 16, Division 3, Title 23, California Cotte of Regulations This toxon must be used to clowringnt losing and servicing of morutortng equipment. A separate *edification or report must be preparers for each morrizoining system control panel by the technician who performs the work. A c5py of this form must be provided to the tank system Ownerlotportltor. The ownertiopemior must submit a copy of mus form to the local agency regulating UST systems vothin 30 days of test date. A. Generallnfomation- Faanty Namc. UNITED PAC 5M6 JIFFY LUSE Bigg. No , Site Address 1403 COUNTRYCLUS BLVD C,ty, STOCKTON CA Zip: 95204 Facility Contact Person. m. Contact Phone No: ( ) Make el of Montionng System RONAN Date of Testing/Servicing, ;}119,"1017 R. inventory of Equipment Test Certified Check thea propirlate boxes to indlcate spoclfic oqui ent ins eetediserviced: Tank ID: 87 Tank Size: Tank 10_ Tank Size: ❑ tn,Tam Gaining Probe, Model: ❑ In -Tank Gauging Probe. el: lel Annular Space or VaA Sensor. Model: LS 10 ❑ Annular Space or vault Seng Model. ❑ Piping Sump 1 Trench S (s) Mod& ❑ Piping Sumo f Trench Sensor(s) el: 0 Fib Sump .'Sensor[sH I' LS3 ❑ Fan Sump Sensor(s) Model: El Mechanical Line Leak Detector Model, ❑ Mochanicai Line Leak Detector. Model: ❑ Electronic line Leak Detector. Model ® Electronic Line Leak Detector. Model: 0 Tank Overfill d High - Sensor, Model L$3 ❑ Tank Overfi I t High-tevet Sea r. Madel: ❑ Other (spoWy equipment type and model in Section E on page 2). _ ❑ Ourier (specify equipment type and model in Section E an Page 2) Tank[D.- DOE Tank Size_ Tank ID; Tank Size: 0 In -Tank Gauging Pry. Model: 0 In -Tank Gauging Probe,Model_ ❑ Annular Space or Vault S Model ❑ Ann`dar Space or Vault Sensor. Model ❑ Piping Sump 1 Trench Sensor(s), Madel: ❑ Piping Sump f Trench 5onsor(s). Model ❑ Fill Sump Sensors) Model: ❑ Fill Sump Sonsof(s) Model ❑ Mechanical tine Leak Detector Model. ❑ Mechanical Line Leak detector Model, ❑ Electronic Line Leak Detector. Model: ❑ Electronic L-ne LenDetector. Model ❑ Tank Overfill I" ffigh-Level Sensor Model, ❑ Tani Overfill P high -Level Sensor. Model: ❑ Outer (specify eqwpmeni type and model in Section E on Page 2). ❑ Other (specfy equipment type and creel in Soebon E on Page 2). Dispenser ID: Dispenser ID: [j wi Containment Sensor(s) Model ❑ Dispenser Containment Sensors) Model ❑ Shear Val"ve(s) ❑ Shear Valves). Dispenser Containment fkaat(s) and Chain(s) ❑ [Dispenser Containment Float(s) and Chain(s). Dispenser ID: DispenserlD: Dispenser Containment Sensor(s). Model ❑ Dispenser Containment Senso(s) Model: ❑ Shear Valve(s) ❑ Shear Valve(s) Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Ftoat(s) and Chain(s). Dispenser ID: Dispenser 10: n' Dispenser Containment ❑ Dispenser ConlainmeritSensot(s) Model: Sensor(s). Model ❑ S rValve(s). n Shear Valve(s). ❑ Dispcnrer Containment Float(s) and Chains} Dispenser Containment Floats) and Chain(s). 'If the facility contains more tanks or da niers, copy this form. Include information for every tank and dispenser at the toolity, C. Certification - l 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 Pitot Plan showing the layout of monitorin equipment= For any equipment capable of generating such reports, l have also attached a copy of lire r*P*tl: (CbeCR Oil thOlap)N9•)t System set-up 0 Alarm history report Technician Name (print): lDav4 Wnnkrer Signature - Certification No.- 5263373 UT License No 08.1735 Testing Company Name, AFFORDA•TEST "4i6 _ Phone No. t2t)9j 744-at12 testing Company Add r aTREIT GALT, C1195Ed32 Date of Testing/Servicing: 5-19-17 Monitoring System Certification Page 1 of 4 2.121 -`0