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Appendix VI ONITORING SYSTEM CERTIFICATION, For Use By All Jurisdictions Within the State of CaliforniarP Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulati2018tiIns 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 ENVIRONMENTAL 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 H FAITH DEPS. RTM ENT A. Generallnformation Facility Name: ANGLE — 99 Bldg. No.: Site Address: 7700 MORELAND RD City: STOCKTON Zip: 95212 Facility Contact erson' ANGLE Contact Phone No.: (209) 957-5398 P Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 8-30-18 B. Inventory of Equipment Tested/Certified Chprk the nnnrnnriatp hnxps to indirste snecifir enuinment insnected/serviced: *If the facility contains more tanks or dispensers, copy this form. Include information for every Tank ID: 87 Tank ID: N/A ❑ In -Tank Gauging Probe. Model: N In -Tank Gauging Probe, Model: MAG 1 N Annular Space or Vault Sensor, Model: 303 ❑ Annular Space or Vault Sensor, Model: N Piping Sump / Trench Sensor(s), Model: 208 304 ❑ Piping Sump /Trench Sensor(s), Model: N Fill Sump Sensor(s). Model: 208 304 ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: N Electronic Line Leak Detector, Model: P L L D ❑ 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: DIE Tank ID: 91 N In -Tank Gauging Probe, Model: MAG 1 ® In -Tank Gauging Probe, Model: MAG 1 N Annular Space or Vault Sensor, Model: 303 N Annular Space or Vault Sensor, Model: SAME TANK N Piping Sump / Trench Sensor(s), Model: 208 304 N Piping Sump /Trench Sensor(s), Model: 208 304 N Fill Sump Sensor(s), Model: 208 304 N Fill Sump Sensor(s), Model: 208 304 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector, Model: N Electronic Line Leak Detector, Model: P L L D N Electronic Line Leak Detector, Model: PLL D ❑ 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: 314 N Dispenser Containment Sensor(s), Model: 208 304 N Dispenser Containment Sensor(s). Model: 208 304 N ❑ Shear Valve(s). Dispenser Containment Float(s) and Chain(s). N ❑ Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: 516 Dispenser ID: 7/8 N Dispenser Containment Sensor(s), Model: 208 304 N Dispenser Containment Sensor(s), Model: 208 304 N ShearValve(s), N ShearVaive(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: VENT Dispenser ID: ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s), Model: 208 304 Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). 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): DAVE WINKLER Certification No.: 834975 Testing Company Name: AFFORDA-TEST Testing Company Address: 416 2nd STREET GALT, CA 95632 Signature: n j License No: 04-1676 Phone No. (209) 744 Date of Testing/Servicing: Monitoring System Certification Page 1 of 4 2/21/07