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Appendix VI MONITORING SYSTEM CERTIFICATION 2 9 .'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 Co"4fifigVations ID t„�qrrp,I 1 111 A This form must be used to do&fndn)t testing and iervi6ing of monitoring equipment.A separate certification or report must be prep&19 each monitoring system controt panel by the'techrilclah 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 LIST systems within 30 days of test date. A. General Information Facility Name: GREWALS GAS Bldg.No.: Site Address: 4100 FREMONT ST City: Zip: Facility Contact Person: RICK Contact Phone No.: ( Make/Model of Monitoring System: VEEDER ROOT TILS 350 Date of Testing/Servicing: 4-23-2015 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate sgecific eguipment inspected/serviced: Tank ID: 87 Tank ID: 91 • In-Tank Gauging Probe. Model: MAG 1 0 In-Tank Gauging Probe. Model: MAG 1 • Annular Space or Vault Sensor. Model: 420 0 Annular Space or Vault Sensor. Model: 420 • Piping Sump/Trench Sensor(s). Model: 208 0 Piping Sump/Trench Sensor(s). Model: 208 0 Fill Sump Sensor(s). Model: [I Fill Sump Sensor(s). Model: 131 Mechanical Line Leak Detector. Model: FE PETRO 0 Mechanical Line Leak Detector. Model: 99LD 2000 0 Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: [I Tank Overfill I High-Level Sensor. Model: El Tank Overfill/High-Level Sensor. Model: [I Other(specify equipment type and model in Section E on Page 2). El Other(specify equipment type and model in Section E on Page 2). Tank ID: DSL Tank ID: NA 0 In-Tank Gauging Probe. Model: MAG I [I In-Tank Gauging Probe. Model: [I Annular Space or Vault Sensor. Model: SPLIT W 91 0 Annular Space or Vault Sensor. Model: ED Piping Sump/Trench Sensor(s). Model: 208 [1 Piping Sump/Trench Sensor(s). Model: 171 Fill Sump Sensor(s). Model: [I Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: 99LD 2000 0 Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: [I Tank Overfill/High-Level Sensor. Model: [I Tank Overfill/High-Level Sensor. Model: [I Other(specify equipment type and model in Section E on Page 2). [1 Other(specify equipment type and model in Section E on Page 2). Dispenser ID: 1-2 Dispenser ID: 6-6 Z Dispenser Containment Sensor(s). Model: 208 0 Dispenser Containment Sensor(s). Model: 208 ED Shear Valve(s). 0 Shear Valve(s). El Dispenser Containment Float(s)and Chain(s). [I Dispenser Containment Float(s)and Chain(s). Dispenser ID: 3-4 Dispenser ID: 7-8 is 0 Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model: 208 9 Shear Valve(s). 0 Shear Valve(s). [I Dispenser Containment Float(s)and Chain(s). El Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: [I Dispenser Containment [I Dispenser Containment Sensor(s). Model: Sensor(s). Model: [I Shear Valve(s). El Shear Valve(s). 0 Dispenser Containment Float(s)and Chain(s). El 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): 0 System set-up 0 Alarm history report Technician Name(print): DAVE WINKLER Signature: Certification No.: 5263373-UT License No: 08-1739 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 2" STREET GALT,CA 95632 Date of Testing/Servicing: 4-23-2015 Monitoring System Certification Page I of 4 2/21/07 Co c I