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Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at htt wwvv waterboards.ca.gov.) 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 Site Address 10858 Trinity Pkwy City: Stockton Zip: 95219 Facility Contact Person: Manager Contact Phone No.: 209-952-2213 Make/Model of Monitoring System: TLS -350R Ver.329.01 Date of Testing/Servicing: 7/19/12 _..- -0 .i.....en+Tn +ori/r'.Arifiarl -it the Tacimy contains muic Lonna ..��r�^�-•-, --r, -..._ .-. C. Certification - 1 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 uiepment For an equipment Alarm history capable f generating such reports, I have also attached a copy of the report; (check a!! that apply): ®r. P Technician Name (print): Ronnie Lewis Signature: Certification No.: A26833 License. No.: 8032737 Testing Company Name: Nucleus Pump Services Phone No.:(530) 644-8465 Testing Company Address: 4960 Pine Tree Ln, Pollock Pines, Ca 95726 Date of Testing/Servicing: 7/19/12 Monitoring System Certification Page 1 of 4 12/07 2/21/07