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Appendix VI i MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of Califomla 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 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 ]] ownerloperalor. 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 Facility Name: KWIK SERV Bldg. No.: S Site Address; 420 KETTLEMEN LANE City: LODI Zip: 96240 Facility Contact Person: JAZ Contact Phone No.: (209) 3894790 Make/Model of Monitoring System: VEEDER ROOT TLS 360 Date of Testing/Servicing: 01-31A8 B. Inventory of Equipment Tested/Certifled Check the appropriate boxes to Indicatespecific a ul ment ins ected(serviced: 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: 407 ® Annular Space or Vault Sensor, Model: 207 ® Piping Sump / Trench Sensor(s) . Model: 208 ® Piping Sump / Trench Sensogs). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leek Detector, Model: 99 LD 2000 ® Mechanical Line Leak Detector, Model: 99 LD 2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Une Leak Detector. Model: ® Tank Overfill / High-level Sensor. Model: FLAPPER ® Tank Overfill i 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: 100 Tank ID: DIE ® in-Tank Gauging Probe, Model: MAG 1 ® In-Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 407 ® Annular Space or Vault Sensor, Model: 407 ® 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 200 ❑ Electronic Une 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). ❑ Outer (specify equipment type and model in Section E on Page 2). Dispenser ID: 1 -2 Dispenser ID: 34 i81 Dispenser Containment Sensor(s), Model: 208 N Dispenser Containment Sensor(s), Model: 208 1 ® ShearValve(s), 19 ShearValve(s), ❑ Dispenser Containment Float(s) and Chaln(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 6-6 Dispenser ID : 7-8 ® Dispenser Containment Sensor(s), Model: 208 ® Dispenser Containment Sensor(s), Model : 208 9 ShearValve(s). ® ShearValve(s). ❑ Dispenser Containment Floal(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 9.10 Dispenser ID: ❑ Dispenser Containment ® Dispenser ContainmentSensor(s). Model: 208 Sensor(s) . Model : ® ShearValve(s). ❑ ShearValve(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 Pict 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: It Certification No.: 5273934-UT License No; 06-1740 Testing Company Name: AFFORDA-TEST Phone No . (209) 744-0113 Testing Company Address: 416 STREET GALT, CA 95832 Date of Tesling/Servicing: 01 -31-18 i Monitoring System Certiflcatlon Page 1 of 4 2/21 /07 i i