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°1 Appendix VI 9 RECEIVED (Copies of Monitoring System Certification form and USTMonitoring Plot Plan available at littp://Nv,,,,,%v.waterboagEcq.,,Illfi 2016 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California ENTAL L1. Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code ofRegul i This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prep m PA41,RTMEN ( 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 of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: Unified Grocers, Inc Facility ID: 01 Site Address: 1990 Piccoli Rd. City: Stockton Zip: 95215 Facility Contact Person: Todd George Contact Phone No.: (209) 931-7431 Make/Model of Monitoring System: Veeder Root TLS -350 Date of Testing/Servicing: 11-21-2016 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: T1 Deisel Tank ID: ❑ In -Tank Gauging Probe. Model: 0 In -Tank Gauging Probe. Model: 847390-109 ® Annular Space or Vault Sensor. Model: 794390-420 ❑ Annular Space or Vault Sensor. Model: Piping Sump /Trench Sensor(s). Model: 794380-205 ❑ Piping Sump/ Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: QMechanical Line Leak Detector. Model: STP-MLLD-D ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line LeakDetector. Model ❑ Electronic Line LeakDetector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: QOther (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: Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Smnp / Trench Sensor(s). Model: ❑ Piping Sump/ Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line LeakDetector. Model: ❑ Electronic Line LeakDetector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ 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 Dispenser ID: ® Dispenser Containment Sensor(s). Model: 794390-420 ❑ Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Cham(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats) and Chain(s). ❑ Dispenser Containment Float(s) and Cham(s). *lf the tacility 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 0 Alarm history report Technician Name (print): Wes Morrison !/V� OL64r1r1Gam Signature: Certification No.: b38044 License. No.: 588098 Testing Company Name: TAIT ENVIRONMENTAL SERVICES Phone No.: 714560-8222 Testing Company Address: 22131 SOUTH DUPONT DRIVE, ANAHETKCA92806 Date of Testing/Seryicing: 11-21-2016