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t t RE !F2W�D Appendix VI G MONITORING SYSTEM CERTIFICATION JUS For Use By All Jurisdictions Within the State of California 17 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 4094 E Ni/ L s-a L ALT each monitoring system control panel by the technician who performs the work.A copy of this form must be provided to the tanks teem owner/operator.The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days oflt tads` , E L n°4 A. General information Facility Name: GREWALS GAS AND LIQUOR Bldg.No.: Site Address: 4100 E FREMONT STREET City: STOCKTON CA Zip: 95215 Facility Contact Person: RICK Contact Phone No.: (209)487-0480 Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 04-06-17 B. Inventory of Equipment Tested/Certified Check the aeEropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: 87 Tank ID: 91 ® 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: 420 SPLIT W DIE ® 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: El Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: FE PETRO ® Electronic Line Leak Detector. Model: PLLD ® Tank Overfill/High-Level Sensor. Model: FLAPPER ® Tank Overfill/High-Level Sensor. Model: FLAPPER ❑ 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: NA Tank ID: DIE ❑ In-Tank Gauging Probe. Model: ® In-Tank Gauging Probe. Model: MAG 1 ❑ Annular Space or Vault Sensor. Model: ® Annular Space or Vault Sensor. Model: 420 SPLIT W 91 ❑ Piping Sump/Trench Sensor(s). Model: ® Piping Sump/Trench Sensor(s). Model: 208 [I Fill Sump Sensor(s). Model: [I Fill Sump Sensor(s). Model: ElMechanical Line Leak Detector. Model: ® 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: FLAPPER ❑ 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: 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: 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: NA Dispenser ID: NA ❑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-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): FELIX RAMIREZ Signature: _ Certification No.: 5273934-UT License No: 08-1740 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 4162 nd STREET GALT,CA 95632 Date of Testing/Servicing: 04-06-17 Monitoring System Certification Page 1 of 2/21/07