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RFCF1VFr_, Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at hftp://www.swrcb.ca.gov.) MONITORING SYSTEM CERTIFICATION MAY 21 2015 For Use By AH Jurisdictions Within the State of California ��(1 f� � n M%� E NTAL Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, Cali �OrA� Regulations HFA! TH I)PPAPTI AF:MT 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 City: STOCKTON Zip: 95219 Facility Contact Person: MANAGER (N-7462-1-10) Contact Phone No.: 209-952-2213 Make/Model of Monitoring System: Veeder Root TLS -350 B. Inventory of Equipment Tested/Certified rt—L, rr.e ti...... r.. ...,if, o....:.....o..r Date of Testing/Servicing: 4/24/2015 Tank ID: Tl - UNLEADED Tank ID: T-2 - PREMIUM r In -Tank Gauging Probe. Model: j- In -Tank Gauging Probe. Model: r Annular Space or Vault Sensor. Model: r Annular Space or Vault Sensor, Model: r Piping Sump / Trench Sensor(s). Model: r Piping Sump / Trench Sensor(s). Model: r Fill Sump Sensor(s). Model: r Fill Sump Sensor(s). Model: r Mechanical Line Leak Detector. Model: r Mechanical Line Leak Detector. Model: r Electronic Line Leak Detector. Model: Veeder Root PLLD r Electronic Line Leak Detector. Model: Veeder Root PLLD 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). Tank ID: T-3 - Diesel Tank ID: r In -Tank Gauging Probe. Model: r In -Tank Gauging Probe. Model: r Annular Space or Vault Sensor. Model: r Annular Space or Vault Sensor. Model: r Piping Sump / Trench Sensor(s). Model: r Piping Sump / Trench Sensor(s). Model: r Fill Sump Sensor(s). Model: r Fill Sump Sensor(s). Model: r Mechanical Line Leak Detector. Model: r Mechanical Line Leak Detector. Model: r 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 and model in Section E on Pae 2). Other(specify equipment a and model in Section E on Pae 2). Dispenser Dispenser ID: ID: r Dispenser Containment Sensor(s). Model: F Dispenser Containment Sensor(s). Model: r Shear Valve(s), r Shear Valve(s). F Dispenser Containment Floats and Chain(s). r Dispenser Containment Floats 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). r Dispenser Containment Floats 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 Floats and Chain(s). r Dispenser Containment Float(s) and Chain(s). -it the raclllty contains more tams or alspensers, copy MIS Torm. incivae inrormation Tor every tanK ano dispenser at the racniry. 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 applyr r System set- up r Alarm history report Technician Name (print): Steve Willems Signature: Certification No.: 836743 License. No.: 743160 Class'A' Testing Company Name: Tanknology Phone No.: (800) 800-4633 Testing Company Address: 11000 N, MoPac Expressway Suite 500 Date of Testing/Servicing: Monitoring System Certification Page 1 of 3 4/24/2015 12/07