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li ! i i ! — . Appendix VI 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, Cal i orrila de of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification rtepor n ust be prepared for each monitoring system control panel by the technician who performs the work. A copy of this form must bi p(ovid4 d o the tank system Owner/operator. The ownerloperator must submit a copy of this form to the local agency regulating UST syst rns vAtt in 30 days of test date. it A. General Int'ormatios Facility Name: TRACY76 Bldg, N I Site Address: 2420 W GRANTLINE RD City: -TRACY CA Zip: 95376 Facility Contact Person: PROVEEN Contact Phone No.: j i Makelhtodel of Monitoring System: VEEDER ROOT TLS 350 Date of Tes ng/Se i ng: 512212018 13. Inventory of Equipment Tested/Cerdfied Check the approeriate boxes to indicatespecific a ui ment ins ectedlserviced: Tank ID: 67 Tank Size: Tank ID: 91 ankS z 0 In-Tank Gauging Probe. Model. MAG 1 ❑ In-Tank Gauging Probe. Model MAGI ® Annular Space or Vault Sensor. Moder. 420 p Annular Space or Vault Sensor Model 420 SPLIT W DSL * Piping Sump / Trench Sensof(s). Model 205 Il Piping Sump / Trench Sensor(s). Model 205 ❑ FII Sump Sensor(s). Model: ❑ FII Sump Sensor(s). Model © Mechanical Line Leak Detector. Model: 99 LD 2000 © Mechanical Line Leak Detector. ! Model LD 2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector, Mi ❑ Tank Overfill / High-Level Sensor. Model: [I Tank Overfill / High-Level Sensor. Model • ❑Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and Ode1 lection E on Page 2). Tank ID: DIE Tank Size: Tank ID: Tan ize: ® in-Tank Gauging Probe. Model: MAGI ❑ In-Tank Gauging Probe. r Mo ei • Annular Space or Vault Sensor. Model: 420 SPLIT W 91 ❑ Annular Space or Vault Sensor. Mo el :. I Piping Sump / Trench Sensor(s), Model: 205 [1 Piping Sump I Trench Sensogs). : ' h10 el [I FII Sump Sensor(s). Model: ❑ FII Sump Sensm(s). ! Mo el El Mechanical Line Leak Detector. Model: LD 2000 ❑ Mechanical Line Leak Detector. Moc el ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector Motel ❑ Tank Overfill / High-Level Sensor. Model: ❑ Tank Overfill / High-Level Sensor. Model ❑ Other (specify equipmentlype and model in Section E on Page 2). ❑ Other (specify equipment type and Indideli ection E on Page 2). DispenserlD: 14 Dispenser ID: 74 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s) ! Mo el ® Shear Valve(s). 0 Shear Valve(s). El Dispenser Containment Float(s) and Chain(s). © Dispenser Containment Float(s) ai I ' hain(s DispenserlD: 3 4 Dispenser 9-101 TI _ ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s) MO ' CI Shear Vaive(s). ® Shear Valve(s). j I © Dispenser Containment Float(s) and Chain(s). ® Dispenser Containment Floal(s) a Chair (s . DispenserlD: DlspenserlD: ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: Sensor(s). Mo ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float ); end i ain(s). ' If the facility contains more tanks or dispensers, copy this form. include information for every tank and dispenser at the faalit C. Certification - I certify that the equipment identified In this document was inspectedlserviced in accordance with the ranufaccin revs' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this t fdrarallo i Is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, have Is 3 attached a copy of the report; (checkall thatapply): ® System sGVup Q Alarm history report Technician Name (print): David Winkler Signature: Certification No.: 8883059-UT License No: 08-1739 Testing Company Name: AFFORDA-TEST Phone No. (209)_744-0112 Testing Company Address: 416 2''' STREET GALT, CA 95632 Date of Testing/Servicing: _ 5-22-18 Monitoring System Certification Page 1 of 4 i .