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"Saw,Appendix VI Vtf MONITORING SYSTEM CERTIFICAt Ny 4 `012 For Use By All Jurisdictions Within the California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, Californ ulations FRMIT �tkThis form must be used to document testing and servicing of monitoring equipment. A separate certification or r�j�led for each monitoring system control panel by the technician who performs the work. A copy of this form must be providedem 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 N.—COUNTRYSIDE MINI MART Site Aritiracc• 14971 N. HWY 99 Facility Contact Parcnn Make/Model of Monitoring System: VEEDER ROOT TLS -350 Bldg. No.: City: LODI Zip: 95240 Contact Phone No.: B. Inventory of Equipment Tested/Certified Check the aoorooriate boxes to indicate specific eauioment inspected/serviced: Date of Testing/Servicing: 4/24/2012 Tank ID: 87 Tank Size: Tank ID: Tank Size: ® In -Tank Gauging Probe. Model: E In -Tank Gauging Probe. Model: MAG 2 E Annular Space or Vault Sensor. Model: 420 ® Annular Space or Vault Sensor. Model: E Piping Sump / Trench Sensor(s). Model: 208 ® Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: E Mechanical Line Leak Detector. Model: STP -MLD ❑ 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 Eon Page 2). Tank ID: DIE Tank Size: Tank ID: 91 Tank Size: E In -Tank Gauging Probe. Model: MAG 2 ® In -Tank Gauging Probe. Model: MAG 2 Annular Space or Vault Sensor. Model: SAME TANK E Annular Space or Vault Sensor. Model: SAME TANK E Piping Sump / Trench Sensor(s). Model: 208 E Piping Sump / Trench Sensor(s). Model: 208 1jj Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s), Model: E Mechanical Line Leak Detector. Model: 99 LD 2000 ® Mechanical Line Leak Detector. Model: 99 LD 2000 ❑ 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). Dispenser ID: 1/2 !Spenser ID: 3/4 E Dispenser Containment Sensor(s). Model: 208 E Dispenser Containment Sensor(s). Model: 208 E Shear Valve(s). E Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: E Dispenser Containment Sensor(s), Model: E Dispenser Containment Sensor(s). Model: E Shear Valve(s). E Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ® Dispenser Containment E Dispenser Containment Sensor(s). Model: Sensor(s). Model: E Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(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; (check all that apply): E System set-up E Alarm history report Technician Name (print). ZANE NIMMO Signature: _y Certification No.: A28446 License No: 04-1676 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 Testing Company Address: 4162 nSTREET GALT, CA 95632 Date of Testing/Servicing: 4/24/12 Monitoring System Certification 1b,4Szz_ Page 1 of 4 2/21/07