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Appendix VI <br />MONITORING SYSTEM CERTIFICATION <br />For Use By All Jurisdictions Within the State Of California <br />Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations <br />This form must be usied to document testing and servicing of monitoring equipment. A separate certficatpon or ;epDn must be prepared for <br />ean moni" System control panel by the lechnician who performs the work A copy of this form must be provided to the tank system <br />ownerloperator. The ownerloperalor Must, Submit a copy of this form to the local agency regulating UST systems within 30 days of lost Catte, <br />A General InfarmaWn <br />Facility Nam. UNITI'D PACIFIC';: 5446 <br />Bldg. No.: <br />Site Address: 1403 COUNTRY CLUB BLVD <br />City: STOCKTON zip: 2$204 <br />FaaMy Contact Person, <br />Contact Phone No.: ( <br />Mak&Modcq of Monitoring System VEU- VER ROOT 112% 35fS --Date of 'restingiServicing: RIW17 RETEST FLOAT <br />B_ Inventory of Equipment Teste&Ceitifiied <br />Check the aPpropliate boxes to inclicalte specific equipment edfserviced: <br />Tank 10: 87 Tank Size; <br />Tank 10: 91 Tank Sizw <br />0 In -Tank Gauging Probe, Model. NIAG -1 <br />0 in -Tank Gauging Probe, Model MAA( l <br />0 Amulas Space or Vault Sensor, model: 302 <br />0 Annular Space or Vault Sensor Model 302 <br />0 Piping Sump i Trench Sensorts). model: 208 <br />0 Piping Sump I Trench Sensor(s). MOOe'r 209 <br />0 Fin Sump Senscir(s) Model, <br />0 Fill Sump Sonsoc(s). Model: <br />0 Mechanical Line Leak Model LD20) <br />0 Mechanical Line Leak Detector Model: LD2000 <br />0 Flectror6c Line Leak Detector Model, — <br />[I Electronic Line Leak Detector. model, <br />0 Tank Overfill i High -Level Sensor. Model, FLAPPER <br />0 Tank Overfill I High -Lever Senter. model: FI_j%PPI-'R <br />1 0 Other (specify equipment W and of in Section E on Page 2). <br />0 Other (specify equipment type and model in Secion E on Page 2). <br />Tank 113: DIE Tank Size-- <br />Tank ID: Tank Size, <br />0 In -Tam Gauging Probe- Model: MAU- 1 <br />0 In -Tank Gauging Probe. model. <br />M Annular -Space or Vault Sensor Model: 303 <br />0 Annular Space or Vault Sensor. Model - <br />0 Piping Sump I Trench S"sor(s). Model 208 <br />0 Piping Sump I Trench Sensor(s) Model: <br />0 Fill Sump Sensor(s). Model- <br />El Fill Sump Sensor(s). Model: <br />0 M Line Leak Deleelor, Model- LD2000 <br />0 Mechanical Line Leak Detector, Model: <br />0 Elactironoc Lone Leak Detector &Wei <br />0 Electronic Line Leak Detector. mow. <br />0 Tank Overfill / High -Level Sensor, Model; FLAPPER <br />C) Tank Overfill / High -Level Se nw- Model: <br />0 Other (specrtir equipment type and model in Section E on Page 2). <br />tj Other (specify equipment type and model in Section E on Page 2) <br />Dispenser ID: 1-2 <br />Dispenser ID: 34 <br />0 Dispenser Containment Serigor(s)_ Model: <br />0 Dispenser Containment Sensor(*). Model - <br />0 ShearValve(s) <br />0 Shear Valve(s). <br />0 DiVenser Ccinlainment Float(s) and Chain(s). <br />0 Dispenser Containment Float(s) arid Chain(s). <br />Dispenser 10: 5-6 <br />Dispenser ID: 7.8 <br />0 Dispenser Contairawl Senser(s). Model, <br />0 Dispenser Containment Serisor(s) Model: <br />0 Shear Marvels) <br />LA Shear Valve(s). <br />13 Dispensec Containment Frons) and Chain(s) <br />Dispenser Containment Floatfs) and Chain(s). <br />Dispenser ID: <br />DispenserID: <br />n Dispenser Containment <br />0 Dispenser Containment Serwr(s), Model: <br />Sensor(s). moi:10 <br />0 ShearValvels) <br />Ej Shear valve(s). <br />'1t the taarrty contains re tarelcg or tlispenser5. Copy U9is foM1 ! uda snfGtmatipez fipr every tank and dL�penser at the facility. <br />C. O"fication - I certify that the equipment Identified In this document was InspectediservicLd in accordance with the manufacturers' <br />guidelines. Attached to this Certification Is information (e.g. manufactuferiV chockil6ts) necessary to verity that this Information is correct <br />and a Plot Plan showing the layout of monkodrit; oQuipment. For any equipment capable of generating such reports, I have also attached a <br />copy of the report, reh"A &A thar apply): 10 System set-up <br />19 Alarm history report <br />techntrjanName (prinly Devilivvinkieir <br />signature: <br />Cen,fication No — 5263373 -UT T <br />LicenseNo. <br />Testing Company Name AFFORDA-TEST <br />Phone No 209 744-0113 <br />Testing Company Address T162 'STREETdALT.ICA94632 <br />Dale of t estinglServicing: $d 14!'7 <br />Monitoring System Certification <br />Page I of 2 2.1147 <br />