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Appendix VI i 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 Cade 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 ownerloperator. The ownerloperator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date, j A. General Information Facility Name: KWIK SERV Bldg. No. : Site Address: 420 KETTLEMEN LANE City: LODI Zip, 96240 Facility Contact Person: JAZ Contact Phone No.: (209) 369-2790 Make/Model of Monitoring System: VEEDER ROOT TLS 360 Date of Testing/Servicing: 01-31 -18 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicatespecific a ul ment Ins acted/serviced: TanklD : 87 TankiD: 91 i ® In-Tank Gauging Probe, Model: MAG 1 ® In-Tank Gauging Probe. Model: MAGI I ® Annular Space or Vault Sensor. Model: 407 ® Annular Space or Vault Sensor, Model: 207 ® Piping Sump / Trench Sensor(s), Model: 208 ® Piping Sump 1 Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model : ❑ Fill Sump Sensor(s). Model: I@ 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: N 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: 100 TanklD: DIE ® In-Tank Gauging Probe, Model: MAG 1 )FQ In-Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor, Model: 407 ® Annular Space or Vault Sensor. Model: 407 ® Piping Sump I Trench Sensor(s). Model: 208 i9 Piping Sump / Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model' ® Mechanical Line Leak Detector, Model: 89 LD 2000 ® Mechanical Line Leak Detector. Model: 99 LD 200 ❑ Electronic Line Leak Detector. Model: ❑ Electronic tine Leak Detector. Model: ® Tank Overfill / High-Level Sensor. Model: FLAPPER ® Tank Overfill 1 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). Dispenser ID : 1 -2 Dispenser ID: 34 Dispenser Containment Sensor(s), Model: 208 ® Dispenser ContainmentSensor(s). Model: 208 1 ShearValve(s), ® ShearValve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chaln(s). Dispenser ID: 6-6 Dispenser ID: 7-8 ® Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s), Model : 208 ® ShearValve(s). ® ShearValve(s). ❑ Dispenser Containment Floal(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chaln(s). DispenserlD: 9"10 Dispenser ID: ❑ Dispenser Containment ® Dispenser Containment Sensor(s), Model: 208 Sensor(s) . Model : ® Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Floats) " tTIn(s).,; 'If the facility contains more tanks or dispensers, copy this form, include information for every tank and dispenser at the faculty. 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 roports, I have also attac�4d a y= r i i C� copy of the report; (check all that apply); ® System setup ( Alarm history report - Technician Name (pdnt): FELIX RAMIREZ Signature: ( ' R CertVicatlon No.: 5273934-UT License No: 08-1740 } Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 r t Testing Company Address: 416 STREET GALT, CA 95632 Date of Tesling/Servicing: 01 -31-18 r Monitoring System Certification Pagel of 4 2/21/07 I I i 1