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. r 77 Appendix VIyown .<� (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.waterboards.ca.gov.) MONITORING SYSTEM CERTIFICATION fl C r 7 For Use By All Jurisdictions Within the State of California ` R1- Authority Cited.Chapter 6.7,Health and Safety Code,Chapter 16,Division 3, Tule 23,California Code ofRtions This form must be used to document testing and servicing of monitoring equipment.A separate certification or repo �uVtt e 1ri%f-Mb L1 CA g Lj monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank vp r/o er'dtor. owner/operator must submit a copy o f this form to the local agency regulating UST systems within 30 days of test date. " A. General Information Facility Name: Unified Grocers,Inc. Building No.: 01 Site Address: 1990 Piccoli Road City: Stockton Zip: 95215 Facility Contact Person: Mike Young Contact Phone No.: 209-931-7416 Make/Model of Monitoring System: Veeder Root TLS-350 Date of Testing/Servicing: 11/18/2014 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: TI:Diesel Tank ID: In-Tank Gauging Probe. Model: 847390-109 In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 794390420 (E Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: 794380-205 '(F Piping Sump/Trench Sensor(s). Model: F� EEE Fill Sump Sensor(s). Model: F Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: STP-MLD-D F Mechanical Line Leak Detector. Model: F Electronic Line Leak Detector. Model: F Electronic Line Leak Detector. Model: F Tank Overfill/High-Level Sensor. Model: F Tank Overfill/High-Level Sensor. Model: F Other(specify equipment type and model in Section E on Page 2). F Other(specify equipment type and model in Section E on Page 2). Tank ID: Tank ID: F In-Tank Gauging Probe. Model: F In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: F Annular Space or Vault Sensor. Model: F Piping Sump/Trench Sensor(s). Model: F Piping Sump/Trench Sensor(s). Model: F Fill Sump Sensor(s). Model: F Fill Sump Sensor(s). Model: F Mechanical Line Leak Detector. Model: F Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: r Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: F Tank Overfill/High-Level Sensor. Model: Other(specify equipment type and model in Section E on Page 2). F Other(specify equipment type and model in Section E on Page 2). Dispenser ID: Dispenser ID: Dispenser Containment Sensor(s). Model: F Dispenser Containment Sensor(s). Model: F Shear Valve(s). F Shear Valve(s). F Dispenser Containment Float(s)and Chain(s). F Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: r Dispenser Containment Sen so 4s). Model: F Dispenser Containment Sensor(s). Model: F Shear Valve(s). F Shear Valve(s). F Dispenser Containment Float(s)and Chain(s). 11 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 F Alarm history report Technician Name(print): Victor Guerrero Signature: Certification No.: B36532 License.No.: 588098 Testing Company Name: TAIT ENVIRONMENTAL SERVICES Phone No.: 714560-8222 Testing Company Address: 2131 SOUTH DUPONT DRIVE.ANAHEIM,CA92806 Date of Testing/Seryicing: 11/18/2014