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s : Appendix VI r MONITORING SYSTEM CERTIFICATION MASS �`� �,1 c919 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 AL`fH This form must be used to document testing and servicing of monitoring equipment. A separate certification o6404!0tustbe prepared for each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to thy tank lays IT 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: GREWAL' S GAS & LIQUOR Bldg . No. : Site Address: 4100 E . FREMONT STREET city: STOCKTON Zip: 95215 Facility Contact Person: RICK GREWAL Contact Phone No. : ( ) Make/Model of Monitoring System: GILBARCO E M C Date of Testing/Servicing : 4/5 /2018 B . Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment Ins ected/serviced : Tank ID : 87 OCT Tank Size : 12 K Tank ID : Tank Size: N In-Tank Gauging Probe, Model : M A G 2 ❑ In-Tank Gauging Probe, Model : N Annular Space or Vault Sensor. Model : 4 2 0 ❑ Annular Space or Vault Sensor. Model : N Piping Sump / Trench Sensor(s) , Model : 2 0 8 ❑ Piping Sump / Trench Sensor(s). Model : ❑ Fill Sump Sensor(s). Model : ❑ Fill Sump Sensor(s), Model : N Mechanical Line Leak Detector. Model : STP - MLD ❑ 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). Tank ID : DIESEL Tank Size: 6 K Tank ID : 91 OCT Tank Size: 6 K N In-Tank Gauging Probe . Model M A G 1 N In-Tank Gauging Probe. Model: M A G 2 N Annular Space or Vault Sensor, Model : 4 2 0 N Annular Space or Vault Sensor, Model : SHARED W/ DSL N Piping Sump / Trench Sensor(s) . Model : 2 0 8 N Piping Sump / Trench Sensor(s). Model : 2 0 8 ❑ Fill Sump Sensor(s). Model : ❑ Fill Sump Sensor(s). Model : ® Mechanical Line Leak Detector. Model . 99 LD 2000 Z Mechanical Line Leak Detector. Model: 99 LD 2000 ❑ 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 : 3 4 ® Dispenser Containment Sensor(s), Model : 2 0 8 ® Dispenser Containment Sensor(s) . Model : 2 0 8 N 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 N Dispenser Containment Sensor(s) . Model : 2 0 8 N Dispenser Containment Sensor(s). Model : 2 0 8 N Shear Valve(s). N Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain (s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID : Dispenser ID : ❑ Dispenser Containment Sensor(s), Model : E] Dispenser Containment Sensor(s). Model : ❑ Shear Valve(s). ❑ Shear Valve(s). E] Dispenser Containment Float(s) and Chain (s) . El 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) : N System set-up ® 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 2nd STREET GALT, CA 95632 Date of Testing/Servicing : 4/5 /2018 Monitoring System Certification Page 1 of 4 2/21 /07