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AUG U 6 2 Appendix VI MONITORING SYSTEM CERTIFICATION ENTALBy All Jurisdictions Within the State of California ENVIRONMAuthority Cited: Chap E 4�ty 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 NSAN JOAQUIN CO. -- DOWNTOWN GARAGE AMA. an,A• Bldg. No.: Site121 S. SAN JOAQUIN ST. AridrRc. City: STOCKTON zip: 95202 Facility Contact Ppmon, CONNIE Contact Phone No.: ( ) Make/Model of Monitoring System: VEEDER ROOT TLS -350 Date of Testing/Servicing: 7/30/2012 B. Inventory of Equipment Tested/Certified Mific equipMnent ins Check the appropriate boxes to indicates=p ted/serviced: Tank ID: 87 Tank Size: 9,684 Tank ID: Tank Size: ® In -Tank Gauging Probe. Model: MAG 1 ® In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 409 ® Annular Space or Vault Sensor. Model: ® Piping Sump / Trench Sensor(s). Model: 208 ® Piping Sump / Trench Sensor(s). Model: ® Fill Sump Sensor(s). Model: 208 ❑ 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: Tank Size: Tank ID: Tank Size: ® 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). Madel: ® Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: 4D Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Madel: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: El 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 Dispenser ID: 2 ® Dispenser Containment Sensor(s). Model: 205 ® Dispenser Containment Sensor(s). Model: 205 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: VAPOR POT SUMP Dispenser ID: ® Dispenser Containment Sensor(s). Model: 208 ❑ 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). DispermerID: Dispenser 10: ❑ 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). '1f 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 monitorin equipment For any equipment capable of generating such reports, I have also attached a copy of the report; (check aAthar apply): D9 System set-up i@ Alarm history report Technician Name (print): ZANE NIMMO Signature: Certification No.: A28446 License No: 04-1676 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 Testing Company Address: 416 STREET GALT, CA 95632 Date of Testing/Servicing: 7/30/12 Monitoring System Certification Page 1 of 4 2/21/07