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Appendix VI (Copies of Monitoring System Certification form and USTMonitoring Plot Plan available at http:"yv a .Naatcrboards.Ct.gov .) MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority Cited.Chapter 6.7,Health andSafety Cade,Chapter 16,Division 3, Title 23,California Code ofRegulations This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be prepared for each monitoring system control panel by the technician 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 ofthis 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)931-7431 Make/Model of Monitoring System: Veeder Root TLS-350 Date of Testing/Servicing: 11/25/2013 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: TLDSL Tank ID: In-Tank Gauging Probe. Model: 847390-109 F In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 794390420 Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model 794380-205 Piping Sump/Trench Sensor(s). Model: F Fill Sump Sensor(s). Model: r Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: STP-MLD-D F Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: F Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: F Tank Overfill/High-Level Sensor. Model: F Other(specify equipment type and model in Section on Page 2). r Other(specify equipment type and model in Section on Page 2). TanklD: TankID: F In-Tank Gauging Probe. Model: In-Tank Gauging Probe. Model: F Annular Space or Vault Sensor. Model Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: r 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: F Electronic Line Leak Detector. Model: F 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 on Page 2). Other(specify equipment type and model in Section on Page 2). Dispenser ID: TLDSL Dispenser ID: F Dispenser Containment Sensor(s). Model: 794390420 F Dispenser Containment Sensor(s). Model: F Shear Valve(s). F Shear Valve(s). F Dispenser Containment Float(s)and Chain(s). F Dispenser ContauunentFloat(s)and Cham(s). Dispenser ID: Dispenser ID: Dispenser Containment Sensor(s). Model: F Dispenser Containment Sensorts). Model: F Shear Valve(s). F Shear Valve(s). F Dispenser ContainmentFloat(s)and Chain(s). F Dispenser ContainmentFloat(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 informations correctand 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) : F 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 soUTfrOUPONTnRIVE,AMAM CA92806 Date of Testing/S ery icing: 11/25/2013