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4, Appendix VI 4P RECEIVED MONITORING SYSTEM CERTIFICATION 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 JULf of This form must be used to document testing and servicing of monitoring equipment. A separate certification or rep a r each monitoring system control panel by the technician who performs the work. A copy of this form must be provi L Li owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 3 i S A. General information Facility Name: LODI PAC PRIDE Bldg. No.: Site Address: 351 N BECKMAN RD City: LODI CA Zip: Facility Contact Person: TED Contact Phone No.: ( ) Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 630-2004 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific enuinment insn2ctart/cs±rviratil- Tank ID: Signature: j Tank ID: License No: 08-1739 ® in -Tank Garaging Prof. Model: ® In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: ® Annular Space or Vault Sensor. Model: ® Piping Sump/ Trench Sensor(s). Model: ® Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: ® Mechanical Line Leak Detector. Model: ❑ 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: Tank ID: NA ® in -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ® Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ® Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: 1 ❑ 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: 5-6 ® 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: 3-4 Dispenser ID: 7-8 ® Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensogs). 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). n me raouty twmams more tanKs or aispensers, copy this form. Include information for evory 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 Pian showing the layout of monitoring equipment. For any equipme&. capable of generating such reports, i have also attached a copy of the report; (check all that apply): 0 System set-up I@ Alarm history report Technician Name (print): DAVE WINKLER Signature: j Certification No.: 5263373 -UT License No: 08-1739 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 Testing Company Address: 4162 nSTREET GALT CA 95632 Date of Testing/Servicing: 6-30-14 Monitoring System Certification Page 1 of 4 2/21/07