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Appendix VI RE Pap ��(Copies of Monitoring System Certification form and UST Monitorin Plot Plan available at htt ://WWW. vvr9 P MONITORING SYSTEM CERTIFICATION �I(!N ® 4 20 14 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,tirA� Regulations FdFAM4 nFNRTMENT 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 Facility Contact Person: MANAGER (N-7462-1-10) Make/Model of Monitoring System: Veeder Root TLS -350 B. Inventory of Equipment Tested/Certified Charie tha annrnnrinta hnvac to inriirata cnarifir anuin-f incnnrtnA /m Ai A - Zip: 95219 Contact Phone No.: 209-952-2213 Date of Testing/Servicing: 5/16/2014 Tank ID: Tl - UNLEADED Tank ID: T-2 - PREMIUM r In -Tank Gauging Probe. Model: In -Tank Gauging Probe. Model: F Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: f Piping Sump / Trench Sensor(s). Model: Fill Sump Sensor(s). Model: r Fill Sump Sensor(s). Model: {� Mechanical Line Leak Detector. Model: r Mechanical Line Leak Detector. Model: jW Electronic Line Leak Detector. Model: Veeder Root PLLD Electronic Line Leak Detector. Model: Veeder Root PLLD r Tank Overfill / High -Level Sensor. Model: Tank Overfill / High -Level Sensor. Model: r Other(specify equipment a and model in Section E on Page 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: Annular Space or Vault Sensor. Model: r Annular Space or Vault Sensor. Model: r Piping Sump / Trench Sensor(s). Model: i` Piping Sump / Trench Sensor(s). Model: Fill Sump Sensor(s). Model: r Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: r Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Veeder Root PLLD Electronic Line Leak Detector. Model: j" 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). j� Other(specify equipment a and model in Section E on Page 2). Dispenser Dispenser ID: ID: r Dispenser Containment Sensor(s). Model: I— Dispenser Containment Sensor(s). Model: r Shear Valve(s). r Shear Valve(s). r Dispenser Containment Float(s) and Chain(s). r 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). r 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). r 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): r System set- up r Alarm history report Technician Name (print): Ryan Casey Certification No.: B38961 Testing Company Name: Tanknology Signature: License. No.: 743160 Class'A' Phone No.: (800) 800-4633 Testing Company Address: 11000 N. MoPac Expressway Suite 500 Date of Testing/Servicing: 5/16/2014 Monitoring System Certification Page 1 of 4 12/07