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t 1 RECEIVED Appendix VI APR 2 3' 2018 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 Coc[§14y1 lWML0 A[ This form must be used to document testing and servicing of monitoring equipment.A separate certification or report AWjA$Tdp6QFf&?ART(AENT 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 LIQUORS Bldg.No.: Site Address: 2512 E. WATERLOO RD City: STOCKTON zip: 95219 Facility Contact Person: HENG OR FONG Contact Phone No.: ( ) Make/Model of Monitoring System: INCON EMS-550 Date of Testing/Servicing: 4/5/2018 B. Inventory of Equipment Tested/Certified Check thea ro nate boxes to indicatespecific equipment ins ected/serviced: Tank ID: 87 OCT Tank Size: 12 K Tank ID: Tank Size: ® In-Tank Gauging Probe. Model: M A G ❑ In-Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: U L S ❑ Annular Space or Vault Sensor. Model: ® Piping Sump/Trench Sensor(s). Model: U L S ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: 99 LD 2000 ❑ 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: DIESEL Tank Size: 8 K Tank ID: 91 OCT Tank Size: 4 K ® In-Tank Gauging Probe. Model: M A G ® In-Tank Gauging Probe. Model: M A G ® Annular Space or Vault Sensor. Model: U L S ® Annular Space or Vault Sensor. Model: SHARED W/ DSL ® Piping Sump/Trench Sensor(s). Model: U L S ® Piping Sump/Trench Sensor(s). Model: U L S ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® 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: I / 2 Dispenser ID: 3 / 4 ® Dispenser Containment Sensor(s), Model: U L S ® Dispenser Containment Sensor(s). Model: U L S ® 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). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). DispenserID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment 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): ZANE NIMMO Signature: Certification No.: A28446 License No: 04-1676 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0112 Testing Company Address: 416 2nd STREET GALT,CA 95632 Date of Testing/Servicing: 4/5/2018 Monitoring System Certification Page 1 of 4 2/21/07