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T Appendix VI MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California RECEIVED Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California CodeofRegulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared fo� 11 ��nIv 2 1 2013 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 A. General Information HEALTH ISE ART E T Facility Name: PACIFIC CAR WASH Bldg. No.: Site Address: Facility Contact Parcnrc 4405 PACIFIC BLVD. TAMMI Make/Model of Monitoring System: VEEDER ROOT TLS -350 City: STOCKTON Contact Phone No.: B. Inventory of Equipment Tested/Certified Check the aoorooriate boxes to indicate specific eauioment inspected/serviced: zip: 95207 Date of Testing/Servicing: 5/23/2013 Tank ID: 87 Tank Size: Tank ID: 91 Tank Size: ® In -Tank Gauging Probe. Model: MAG 1 ® in -Tank Gauging Probe. Model: MAG I ® Annular Space or Vault Sensor. Model: 420 ® Annular Space or Vault Sensor. Model: SAME VESSEL ® 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: ❑ 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: TRANSITION Tank Size: 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: 323 ❑ 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: 1/2 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 Dispenser ID: 7/8 ® 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: 9/10 Dispenser ID: 11/12 ® Dispenser Containment ® Dispenser Containment Sensor(s). Model: 208 Sensor(s). Model: 208 ® 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: OAVEE— Certification No.: A28446 License No: 04-1676 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 Testing Company Address: 4162 nSTREET GALT, CA 95632 Date of Testing/Servicing: 5/23/13 Monitoring System Certification Page 1 of 4 C a 11 1 .,;,, ld ._ 1i 2/21/07