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t ,J VE4 Appendix VI Apia 2 4r MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority GI e 1 h and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to oct! d servicing of monitoring equipment. A separate certification or report must be prepared for each monitoring system control panel by the echnician who performs the work. A copy of this form must be provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility _ Name: PARKWOOD SHELL Bldg. No.: Site Address: 1612 W HAMMER LN City: STOCKTON Zip:," 95209 ' Facility Contact Person: PAUL Contact Phone No.: (209) 931-3549 Make/Model of Monitoring System: VEEDER ROOT TLS 350. Date of Testing/Servicing: 07-27-12 .B. Inventory, of Equipment Tested/Certified - - Check theappropriate boxes to indicate specific equipment inspected/serviced: Tank ID: 87 Tank ID: 91 ❑ In -Tank Gauging Probe. Model MAG Z ED In -Tank Gauging Probe. Model: MAG 2 ® Annular Space or Vault Sensor. Model: 420 ® Annular Space or Vault Sensor. Model: 420 -❑ Piping Sump / Trench Sensor(s), Model: 208 -® Piping Sump / Trench Sensor(s). Model 208 ❑ Fill Sump Sensor(s). Model ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: 99 LD 2000. ® Mechanical Line Leak Detector. Model: 99 LD 2000,. -❑ Electronic tine Leak Detector: - Model ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: FLAPPER ED Tank Overfill) High -Level Sensor.Model: FLAPPER l " Other (specify equipment type and model in Section E on Page 2). [1Other (specify equipment type and model in Section "o -Page 2). Tank ID: DIESEL Tank ID: ® In -Tank Gauging Probe. Model: MAG 2 ❑ In -Tank Gauging Probe. Model ® Annular Space or Vault Sensor. Model: 420 SPLIT W 91 -. ❑ Annular Space or Vault Sensor. Model: 0 Piping Sump / Trench Sensor(s). Model: 208 ❑ Piping Sump / Trench Sensor(s). Model El Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model 99 LD 2000 ❑ Mechanical Line Leak Detector. - Model ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: , 0 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). Nspenser ID: 1-2 Dispenser ID: 3-4 ❑ Dispenser Containment Sensor(s) Model ❑ Dispenser Containment Sensor(s). Model ® Shear Valve(s). ® Shear Valve(s). a r ® Dispenser Containment Float(s) and Chain(s). ® Dispenser Containment Float(s) and Chain(s) Dispenser ID: 5-6 Dispenser ID: 7-8 ® Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model: 208 ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ 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 -1 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,4 copy of the report; (check all that apply): ® System set-up ® Alarm history report Technician Name (print): FELIX RAMIREZ Signature: Certification No.: 5273934 -UT License No: 08-1740 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 Testing Company Address: 416 Z STREET GALT, CA 95632 - Date of Testing/Servicing: 07-27-12 Monitoring System Certification Page 1 of 4 2/21/07