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Appendix VI RECEIVED (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://vvww.swrcbT�.po`)9 2017 MONITORING SYSTEM CERTIFICATION For Use By AlI Jurisdictions Within the State of California C 1(� R�,�#,AL HEALTH Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, a for Regulations MENT 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 PLUS B. Inventory of Equipment Tested/Certified rhprk the annrnnriatp hnxpc to indiratp cnprifir Pnninmpnt incnprtpd /cpmirpd- Zip: 95219 Contact Phone No.: 209-952-2213 Date of Testing/Servicing: 3/24/2017 Tank ID: TI - UNLEADED Tank ID: T-2 - PREMIUM ry—o In -Tank Gauging Probe. Model: 846390-109 In -Tank Gauging Probe. Model: 846390-109 r7 Annular Space or Vault Sensor. Model: 794380-303 r%_0 Annular Space or Vault Sensor. Model: 794380-303 (O Piping Sump / Trench Sensor(s). Model: 794380-208 r%_0 Piping Sump / Trench Sensor(s). Model: 794380-208 Fill Sump Sensor(s). Model: 794380-208 Fill Sump Sensor(s). Model: 794380-208 r Mechanical Line Leak Detector. Model: r Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Veeder Root PLLD - f%_0 Electronic Line Leak Detector. Model: Veeder Root PLLD - P Tank Overfill / High -Level Sensor. Model: Flapper/ext alarm r7o Tank Overfill / High -Level Sensor. Model: Flapper/ext alarm Other(specify equipment a and model in Section E on Pae 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: 846390-111 r In -Tank Gauging Probe. Model: Annular Space or Vault Sensor, Model: 794380-303 r Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: 794380-208 r Piping Sump / Trench Sensor(s). Model: r Fill Sump Sensor(s). Model: 794380-208 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 - (— Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: Flapper/ext alarm r Tank Overfill / High -Level Sensor. Model: Other(specify equipment a and model in Section E on Pae 2). Other(specify equipment a and model in Section E on Pae 2). Dispenser 1/2 Dispenser 3/4 ID: ID: i7o Dispenser Containment Sensor(s). Model: 794380-208 r Dispenser Containment Sensor(s). Model: 794380-208 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 5/6 Dispenser 7/8 ID: ID: r Dispenser Containment Sensor(s). Model: 794380-208 Dispenser Containment Sensor(s). Model: 794380-208 Shear Valve(s). rv-0 Shear Valve(s). r Dispenser Containment Float(s) and Chain(s). r Dispenser Containment Float(s) and Chain(s). Dispenser 9/10 Dispenser 11/12 ID: ID: jr Dispenser Containment Sensor(s). Model: 794380-208 r%_0 Dispenser Containment Sensor(s). Model: 794380-208 ry Shear Valve(s). r Shear Valve(s). r Dispenser Containment Float(s) and Chain(s). r Dispenser Containment Float(s) and Chain(s). *It the tacility contains more tanks or tlispensers, copy this torm. Include Intomlatlon for every tank ana alspenser at the tacinty. 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 P Alarm history report Technician Name (print): Steve Willems Certification No.: B36743 Testing Company Name: Tanknology Testing Company Address: 11000 N. MoPac Expressway Suite 500 Monitoring System Certification Signature: License. No.: 743160 Class'A' Phone No.: (800) 800-4633 Page 1 of 4 Date of Testing/Servicing: 3/24/2017 12/07