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E Appendix VI ) 2017 (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at littp://w�aiv.waterboaNDIV. MONITORING SYSTEM CERTIFICATION 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 Code ofRegula tonss nn �� - T HEALTH This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be pre fbr monitoring system control panel by the technician who perforans the work. A copy of this form must be provided to the tank system owner/operator. The oNsmer/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 Site Address: 1990 Piccoli Rd. Facility Contact Person: Todd George Make/Model of Monitoring System: Veeder-root TLS -350 City: Stockton Facility ID: 01 Zip: 95215 Contact Phone No.: (209) 931-7431 Date of Testing/Servicing: 11/08/2017 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: T1 Diesel Tank ID: In -Tank Gauging Probe. Model: 847390-109 ❑ In -Tank Gauging Probe. Model 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: 0 Mechanical Line Leak Detector. Model: STP-MLLD-D ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. 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). 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 Sump/ Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(,). Model ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak D ete ctor. Model: ❑ Electronic Line Leak D ete ctor. 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: ZDispenser Containment Sensor(s). Model: 794390-420 ❑ Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). ❑ Shear Valve(,). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sen sor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(,). ❑ Dispenser Containment F loat(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; (cited all that apply) : Q System set-up ❑i� Alarm history report Technician Name (print): Garrett Warren Certification No B42126 Testing Company Name: TAIT Environmental Services, Inc. Signature: ZUa�utec� License. No.: 588098 Phone No.: 714560-8222 Testing Company Address:701 N Parkcenter Dr., Santa Ana, CA, 92705 Date of Testing/Sery icing: 11/08/2017