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i. Appendix VI MONITORING SYSTEM CERTIFICATION FEB 0 6 2015 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 Co "eS4 This form must be used to document testing and servicing of monitoring equipment. A separate certification or report meach monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the, r► NTpOwner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 day2n tnTq ,rr_,,-r A. General Information: Facility Name: TULARE FARM Bldg. No.: Site Address: 2771 E FRENCH CAMP RD City: FRENCH CAMP CA Zip: Facility Contact Person: Contact Phone No.: Make/Model of Monitoring System: VEEDER ROOT B. Inventory of Equipment Tested/Certified Check the annrondate bones to indicate snecific eauinment insnected/serviced: Date of Testing/Servicing: 1/23/2015 Tank ID: 87 Tank Size: Tank ID: Tank Size: ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 420 ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ 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: DIE Tank Size: Tank ID: ❑ In -Tank Gauging Probe. Tank Size: L? L11 an � Model:�,cQX ❑ In -Tank Gauging Probe. Model: ID Annular Space or Vault Sensor. Model: EIS LIGHT SEN ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ 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). Dispenser ID: 1 GAS Dispenser ID: 2 DSL ISI Dispenser Containment Sensor(s). Model: 001 ® Dispenser Containment Sensor(s). Model: 001 ® 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). 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): David Winkler Signature: Certification No.: 5263373 -UT License No: 08-1739 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0112 Testing Company Address: 416 2" STREET GALT, CA 95632 Date of Testing/Servicing: 1-23-15 Monitoring System Certification Page 1 of 4 2/21/07