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Appendix VI MONITORING SYSTEM CERTIFICATION r 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 must be prepared for each monitoring system control panel by the technician 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 PARKWOOD VALERO Na Site AflftfP.CS' 1612 W. HAMMER LANE City: Facility Contact Parsnn' Make/Model of Monitoring System: GILBARCO / EMC Bldg. No.: STOCKTON Contact Phone No.: B. Inventory of Equipment Tested/Certified Check the aooropriate boxes to indicate specific equipment inspected/serviced: Zip: 95210 Date of Testing/Servicing: 7/28/2011 Tank ID: 87 Tank Size: T k ID: Tank Size: ® In -Tank Gauging Probe. Model: MAG 2 ❑ In- Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 420 ❑ Annular Space or Sensor. Model: ® Piping Sump/ Trench Sensor(s). Model: 208 ❑ Piping Sump/ Trench Sensor s . M ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). I: ® Mechanical Line Leak Detector. Model: 99 LD 2000 ❑ Mechanical Line Lea ector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Li eak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Ta erfill /High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). ❑ ther (specify equipment type and model in Section E on Page 2). Tank ID: DIE Tank Size: Tank ID: 91 Tank Size: ® In -Tank Gauging Probe. Model: MAG 2 ® In -Tank Gauging Probe. Model: MAG 2 ® Annular Space or Vault Sensor. Model: 420 ® Annular Space or Vault Sensor. Model: SAME AS DIESEL ® 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: LD 2000 ® Mechanical Line Leak Detector. Model: 99 LD 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). Dispenser ID: 1&2 Dispenser ID: 3&4 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ® Shear Valve(s). ® 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). ID: Des D: ❑ Dispenser Con a 7[]Dispenser Containment Sensors . Sensor(s). ear Valve(s). ❑ Shear Valve(s r ontainment Float(s) and Chain(s). ❑ r 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): ® System set-up ® Alarm history report. Technician Name (print): Lyle D. Nimmo Signature: Certification No.: 0605 License No: 90-1143 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 Testing Company Address: 4162 nSTREET GALT, CA 95632 Date of Testing/Servicing: 7/28/11 Monitoring System Certification Page 1 of 4 2/21/07