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0 Appendix VI RVE MONITORING SYSTEM CERTIFICATION n For Use By All Jurisdictions Within the State of California or>r 2090 Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, Calif �j Regulations NV 1#E r L TH This form must be used to document testing and servicing of monitoring equipment.A separate certification or reportCES PERMIT�SE Vf must be prepared for each monitoring system control panel by the technician who performs the work.A copy of th s form must be provided to the tank system owner/operator.The owner/operator must submit a copy of this form to the local agency regi ilating UST systems within 30 days of test date. A. General Information Facility Fa lit GREWALS 76 Bldg.No.: Site --- -- ------- ArldrFcc 4100 E FREMONT STREET City STOCKTON CA zip: Facility Contact -- -- - ---- PnrRnn RICK Contact Phone No.: Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 4/29/2010 v B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: 87 oct Tank ID: 91 oct i ® In-Tank Gauging Probe. Model: MAG 1 ® In-T nk Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 420 ® Annular Space or Vault Sensor. Model: 420 ® Piping Sump/Trench Sensor(s). Model: 208 ® Pipi g Sump/Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: FE-PETRO ® Mechanical Line Leak Detector. Model: LD-2000 ❑ Electronic Line Leak Detector. Model ❑ Electronic Line Leak Detector. Model II ❑ Tank Overfill/High-Level Sensor. Model: ❑ TankOverfill/High-Level Sensor. Model: ,, ❑ Other(specify equipment type and model in Section E on Page 2). [1Other(specify equipment type and model in Section E on Page 2) -- i! Tank ID: DSL Tank ID: NA ® In-Tank Gauging Probe. Model: MAG 1 ❑ In-Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: SPLIT W 91 ® Annular Space or Vault Sensor. Model: III ❑ Piping Sump/Trench Sensor(s). Model: ❑ Pipin 3 Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: I ® Mechanical Line Leak Detector. Model: LD-2000 ❑ Mechanical Line Leak Detector, Model: I ❑ Electronic Line Leak Detector. Model: El El onic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: II ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section Ei on Page 2). _ i�Dispenser ID: 1-2 Dispenser ID: 3-4 -_�-- II ❑ Dispenser Containment Sensor(s). Model: 208 ❑ Disp (nser Containment Sensor(s). Model: 208 ® Shear Valve(s). ® Sheat Valve(s). E Dispenser Containment Float(s)and Chain(s). ® Disperiser Containment Float(s)and Chain(s). Dispenser ID- 5-6 Dispen erID: 7-8 _ ❑ Dispenser Containment Sensor(s). Model: 208 ❑ Dispenser Containment Sensor(s). Model: 208 �I ® Shear Valve(s). ® Shear Valve(s). ® Dispenser Containment Float(s)and Chain(s). ® Dispe ser Containment Float(s)and Chain(s). III Dispenser ID: Dispenser ID: ❑ DiSPE nser Containment III ❑ Dispenser Containment Sensor(s). Model: Sens r(s). Model: IIIEl Shear Valve(s). ❑Shea Valve(s). El Dispenser Containment Float(s)and Chain(s). ❑ DispE nser 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/servic d 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 ol 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): DAVE WINKLER Signature: Certification No.: _5263373-UT _ License No 08-1739 --- -- - Testing Company Name: AFFORDA-TESTo. 209 744-0113 — -- Testing Company Address. 416 2" STREET GALT,CA 95632 Date of Testing/Servicing: 4-29-2010 — Monitoring System Certification Page 1 of 4 2/21/07