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Appendix VI HECEIVEC (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.swrcb.ca.gov.) MAY 2 6 2015 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California VVIR 0 N M ENTAL Authority Cited: Chapter 6.7, Health and Safety Code, Chapter 16, Division 3, Title 23, California CodF aC41TU r11=D00T4ACAlT 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: CHEVRON 307709 Bldg. No.: Site Address: 10858 TRINITY PKWY Facility Contact Person: MANAGER (N-7462-1-10) City: STOCKTON Make/Model of Monitoring System: Veeder Root TLS -350 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicate specific equipment inspected/serviced: Zip: 95219 Contact Phone No.: 209-952-2213 Date of Testing/Servicing: 4/24/2015 Tank ID: TI - UNLEADED Tank ID: T-2 - PREMIUM r In -Tank Gauging Probe. Model: r In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: [! Annular Space or Vault Sensor. Model: r Piping Sump / Trench Sensor(s). Model: Piping Sump / Trench Sensor(s). Model: r Fill Sump Sensor(s). Model: r Fill Sump Sensor(s). Model: I— Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: r Electronic Line Leak Detector. Model: Veeder Root PLLD I Electronic Line Leak Detector. Model: Veeder Root PLLD r Tank Overfill / High -Level Sensor. Model: (- Tank Overfill / High -Level Sensor. Model: Other(specify equipment a and model in Section E on Page 2). Other(specify equipment a and model in Section E on Pae 2). Tank ID: T-3 - Diesel Tank ID: In -Tank Gauging Probe. Model: j 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: r Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: r Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: rV Electronic Line Leak Detector. Model: Veeder Root PLLD r Electronic Line Leak Detector. Model: r Tank Overfill / High -Level Sensor. Model: r Tank Overfill / High -Level Sensor. Model: Other(specify equipment a and model in Section E on Pae 2). r Other(specify equipment a and model in Section E on Pae 2). Dispenser Dispenser ID: ID: r Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: r Shear Valve(s). Shear Valve(s). r Dispenser Containment Floats and Chain(s). Dispenser Containment Floats and Chain(s). Dispenser Dispenser ID: ID: I— Dispenser Containment Sensor(s). Model: r Dispenser Containment Sensor(s). Model: F Shear Valve(s). r Shear Valve(s). )— Dispenser Containment Floats and Chain(s). j Dispenser Containment Float(s) and Chain(s). Dispenser Dispenser ID: ID: r Dispenser Containment Sensor(s). Model: r Dispenser Containment Sensor(s). Model: r Shear Valve(s). r Shear Valve(s). r Dispenser Containment Float(s) and Chain(s). [ i Dispenser Containment Floats 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): r System set- up rAlarm history report Technician Name (print): Steve Willems Certification No.: 836743 Signature: License. No.: 743160 Class W Testing Company Name: Tanknology Phone No.: (800) 800-4633 Testing Company Address: 11000 N. MoPac Expressway Suite 500 f Date of Testing/Servicing: 4/24/2015 Monitoring System Certification Page 1 of 3 12/07