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w Appendix VI 0 MONITORING SYSTEM CERTIFICATION SVI 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 certificationor report must FECEIVED each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to thowner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 d A. General information Facility Name: Site Address: Facility Contact Person: PACIFIC CAR WASH Bldg. No.: 4405 PACIFIC AVE TAMMY Make/Model of Monitoring System: VEEDER ROOT TLS 350 Imm City: STOCKTON Zip' 7A LTH Contact Phone No.: (209) 478-5504 PERM)T/SERVICES B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Date of Testing/Servicing: 05-19-14 Tank ID: 87 Tank ID: 91 ® in -Tank Gauging Probe. Model: MAG 1 ® In -Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 420 ® Annular Space or Vault Sensor. Model: 420 SPLIT W 87 ® Piping Sump / Trench Sensor(s). Model: 208 ® Piping Sump / Trench Sensor(s). Model: 208 ❑ 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: 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: Tank ID: TRANSITION SUMP ❑ 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). Model: ® Piping Sump / Trench Sensor(s). Model: 208 ❑ 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: 0 -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 Dispenser ID: 3-4 ® Dispenser Containment Sensor(s). Model: 323 ® Dispenser Containment Sensor(s). Model: 323 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5-6 : 7-8 ® Dispenser Containment Sensor(s). Model: 323 FDispenserontainment Sensor(s). Model: 323 ® ShearValve(s). (s). ❑ Dispenser Containment Float(s) and Chain(s). ontainment Float(s) and Chain(s). Dispenser ID: 9-10 Dispenser ID: 11-12 ® Dispenser Containment ® Dispenser Containment Sensor(s). Model: 208 Sensor(s). Model: 208 ® Shear Valve(s). ® Shear Valve(s). C 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 RAMIREZ Signature: ` r' - Certification No.: 5273934 -UT License No: 08-1740 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 Testing Company Address: 4162 nSTREET GALT, CA 95632 Date of Testing/Servicing: 05-19-14 Monitoring System Certification Page 1 of 4 2/21/07