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0 Appendix VI 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 of Regulations 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 of this form to the local agency regulating UST systems within 30 days of test date. A. General information Facility Name: WATERLOO LIQUOR Bldg. No.: Site Address: 2512 EAST WATERLOO RD City: STOCKTON Zip: Facility Contact Person: HENG Contact Phone No.: ) Make/Model of Monitoring System: INCON EMS -100 Date of Testing/Servicing: 06-29-12 B. Inventory of Equipment Tested/C rtified Check the Mpropriate bi)xes to in ica e specific equipment ins ected/serviced: Tank ID: 87 Tank ID: 91 ® In -Tank Gauging Probe. Model: MAG ® In -Tank Gauging Probe. Model: MAG ® Annular Space or Vault Sensor. Model: ULS ® Annular Space or Vault Sensor. Model: ULS ® Piping Sump / Trench Sensor(s). Model: ULS ® Piping Sump / Trench Sensor(s). Model: ULS ❑ Fill Sump Sensor(s). Model ❑ Fill Sump Sensor(s). Model ® Mechanical Line Leak Detector. Model: LD 2000 ® Mechanical Line Leak Detector. Model: LD 2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: FLAPPER ® Tank Overfill / High -Level Sensor. Model: FLAPPER ❑ 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: DIE Tank ID: ❑ In -Tank Gauging Probe. Model: ® in -Tank Gauging Probe. Model: MAG ® Annular Space or Vault Sensor. Model: ULS ❑ Annular Space or Vault Sensor. Model: ® Piping Sump / Trench Sensor(s). Model: ULS ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: RED JACKET ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: FLAPPER ❑ 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 Dispenser ID: 3-4 ® Dispenser Containment Sensor(s). Model: ULS ® Dispenser Containment Sensor(s). Model: ULS ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). U Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: Sensor(s). Model: ❑ 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): ® System set-up ® Alarm history report Technician Name (print): FELIX Signature: '— Certification No.:5R ED License No: 0e-1740 Testing Company Na Phone No. (209) 744-0113 Testing Company Address: 416 2" STREET GALT, CA 95632 Date of Testing/Servicing: 06-29-12 « r� ff 2017Monitoring System Certificali Page 1 of 4 I - /21/07 U! % �& _0ERMMSERVICES 'IMROMMENTAL HFAETF4