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CENED Appendix V1 J 6-1 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 CodWA66ihWhimL. This form must be used to document testing and servicing of monitoring equipment.A separate certification or report m SPi;e-p,rep-gr6d,,fliif, 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 LIST systems within 30 days of test date. A. General Information Facility Name: PACIFIC CAR WASH Bldg.No.: Site Address: 4405 PACIFIC BLVD city: STOCKTON zip: 95207 Facility Contact Person: TAMMI Contact Phone No.: ( Make/Model of Monitoring System: VEEDER ROOT TLS-350 Date of Testing/Servicing: 5/15/2018 B. Inventory of Equipment Tested/Certified Check thea ro riate boxes to indicates ecific aqulpment inspected/serviced: Tank ID: 87 OCT Tank Size: 12 K Tank ID: 91 OCT Tank Size: 8 K N In-Tank Gauging Probe. Model: M A G 1 0 In-Tank Gauging Probe. Model: M A G I N Annular Space or Vault Sensor. Model: 4 2 0 - NEW Z Annular Space or Vault Sensor. Model: SHARED W/ 870ct 0 Piping Sump I Trench Sensolsl, Model: 2 1 1 0 Piping Sump I Trench Sens,,,s,, Model: 2 0 8 El Fill Sump Sensor(s). Model: [I Fill Sump Sensor(s). Model: — 0 Mechanical Line Leak Detector. Model: 99 LD 2000 0 Mechanical Line Leak Detector. Model: 99 LD 2000 0 Electronic Line Leak Detector. Model: [] Electronic Line Leak Detector. Model: 0 Tank Overfill/High-Level Sensor. Model: E] Tank Overfill/High-Level Sensor. Model: El Other(specify equipment type and model in Section E on Page 2). El Other(specify equipment type and model in Section E on Page 2). Tank ID: Tank Size: Tank ID: Transition Sump Tank Size: El In-Tank Gauging Probe. Model: El In-Tank Gauging Probe, Model: Ej Annular Space or Vault Sensor. Model: E] Annular Space or Vault Sensor. Model: El Piping Sump I Trench Sensor(s). Model: 0 Piping Sump/Trench Sensor(s). Model: 2 0 8 El Fill Sump Sensor(s). Model: El Fill Sump Sensor(s). Model: El Mechanical Line Leak Detector. Model: El Mechanical Line Leak Detector. Model: El Electronic Line Leak Detector. Model: El Electronic Line Leak Detector. Model: [] Tank Overfill/High-Level Sensor. Model: El Tank Overfill/High-Level Sensor. Model: El Other(specify equipment type and model in Section E on Page 2). F-1 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: 3 2 3 Z Dispenser Containment Sensor(s). Model: 3 2 3 • ShearValve(s). 0 ShearValve(s). [I Dispenser Containment Float(s)and Chain(s). E] Dispenser Containment Float(s)and Chain(s). Dispenser ID:_5 / 6 Dispenser ID: 7 / 8 0 Dispenser Containment Sensor(s). Model: 3 2 3 Dispenser Containment Sensor(s). Model: 3 2 3 ED ShearValve(s). ShearValve(s). E] Dispenser Containment Float(s)and Chain(s). El Dispenser Containment Float(s)and Chain(s). Dispenser ID: 9 / 10 Dispenser ID: 11 / 12 0 Dispenser Containment Sensor(s). Model: 2 0 8 N Dispenser Containment Sensor(s). Model: 2 0 8 0 ShearValve(s). ShearValve(s). El 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 N 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 21d STREET GALT,CA 95632 Date of Testing/Servicing: 5/15/2018 Monitoring System Certification Page 1 of 4 2/21/07