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4YtSr6Y APR 11 2016 Appendix VI _ (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.swrcCi � Iv ��TAL -,i-AITU �t'D�4?T1A�AIT MONITORING SYSTEM CERTIFICATION 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, California Code of 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 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 rhPck the annrnnriate hnrac to indiratP cnPrifir nnuinmPnt incnPrtnri /—i—d- Zip: 95219 Contact Phone No.: 209-952-2213 Date of Testing/Servicing: 3/31/2016 Tank ID: TI - UNLEADED Tank ID: T-2 - PREMIUM r In -Tank Gauging Probe. Model: mag r7 In -Tank Gauging Probe. Model: mag Pi Annular Space or Vault Sensor. Model: 794380-303 r Annular Space or Vault Sensor. Model: 794380-303 PF Piping Sump / Trench Sensor(s). Model: 794380-208 r Piping Sump / Trench Sensor(s). Model: 794380-208 +I; Fill Sump Sensor(s). Model: 794380-208 r 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 - r Electronic Line Leak Detector. Model: Veeder Root PLLD - r Tank Overfill / High -Level Sensor. Model: flapper/ext alarm r Tank Overfill / High -Level Sensor. Model: flapper/ext alarm Other(specify equipment a and model in Section E on Pa e 2). r Other(specify equipment a and model in Section E on Pae 2). Tank ID: T-3 - Diesel Tank ID: 7 In -Tank Gauging Probe. Model: mag r In -Tank Gauging Probe. Model: 7 Annular Space or Vault Sensor. Model: 794380-303 r Annular Space or Vault Sensor. Model: r Piping Sump / Trench Sensor(s). Model: 794380-208 r Piping Sump / Trench Sensor(s). Model: 7 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 - r 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 Pa e 2). ri Other(specify equipment a and model in Section E on Page 2). Dispenser 1/2 Dispenser 3/4 ID: ID: Dispenser Containment Sensor(s). Model: 794380-208 [Vj Dispenser Containment Sensor(s). Model: 794380-208 r Shear Valve(s). C Shear Valve(s). Dispenser Containment Floats) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser 5/6 Dispenser 7/8 ID: ID: P7 Dispenser Containment Sensor(s). Model: 794380-208 r Dispenser Containment Sensor(s). Model: 794380-208 F Shear Valve(s). r 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: P Dispenser Containment Sensor(s). Model: 794380-208 r Dispenser Containment Sensor(s). Model: 794380-208 Shear Valve(s). [_Y� Shear Valve(s). Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). -iT the Tacnity contains more tames or aispensers, copy tins Torm. incwae inrormation Tor every tanK and dispenser at the taciiity. 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): W System set- up PF Alarm history report Technician Name (print): Jarrod Cooke Certification No.: 835255 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: 3/31/2016 12/07