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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 , 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 owner/operator. 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: CITY OF STOCKTON CORP YARD Bldg , No. : Site Address: 1466 S LINCLN ST City: STOCKTON CA Zip: 95206 Facility Contact Person: I Contact Phone No. : ( ) Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 4-7-17 Be Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced : Tank ID : 87 TanklD: DSL ® In-Tank Gauging Probe, Model: MAG 1 ® In-Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model : 303 ® Annular Space or Vault Sensor, Model: 303 ® 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: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line 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). ❑ Other (specify equipment type and model in Section E on Page 2). TanklD : TanklD : ❑ In-Tank Gauging Probe. Model: Awe 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: ❑ 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 : 34 DSL ® Dispenser Containment Sensor(s), Model: 406 ® Dispenser Containment Sensor(s), Model: 406 ® 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 DSL ® Dispenser Containment Sensor(s) , Model: 406 ® Dispenser Containment Sensor(s), Model : 406 ® Shear Valve(s). ® Shear Valve(s) . ❑ Dispenser Containment Float(s) and Chain(s) . ❑ Dispenser Containment Floats) and Chain (s). Dispenser ID : Dispenser ID : ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s), Model : Sensor(s) . Model : ❑ 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 Uml apply) : ® System set-up ® Alarm history report Technician Name (print): DAVE WINKLER Signature: Certification No. : 5273934-UT License No: 08-1740 Testing Company Name: AFFORDA-TEST Phone No. (209) 7440112 Testing Company Address: 416 2nd STREET GALT, CA 95632 Date of Testing/Servicing : 4-7-17 Monitoring System Certification Page 1 of 4 2/21 /07