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Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.swrcb.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 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 ('hnrlr thn nnnrnnriatn hnvoe to inrli—to encrifir oniiinmont inenortorl /eurvirorl- Zip: 95219 Contact Phone No.: 209-952-2213 Date of Testing/Servicing: 4/24/2013 Tank ID: T1 - UNLEADED Tank ID: T-2 - PREMIUM r In -Tank Gauging Probe. Model: mag In -Tank Gauging Probe. Model: mag P Annular Space or Vault Sensor. Model: 303 Annular Space or Vault Sensor. Model: 303 Piping Sump / Trench Sensor(s). Model: 208/304 Piping Sump / Trench Sensor(s). Model: 208/304 WO Fill Sump Sensor(s). Model: 208/304 W Fill Sump Sensor(s). Model: 208/304 Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Veeder Root PLLD r Electronic Line Leak Detector. Model: Veeder Root PLLD JV_ Tank Overfill / High -Level Sensor. Model: external alarm rV Tank Overfill / High -Level Sensor. Model: EXTERNAL ALARM r— Other(specify equipment a and model in Section E on Page 2). r— Other(specify equipment a and model in Section E on Page 2). Tank ID: T-3 - Diesel Tank ID: In -Tank Gauging Probe. Model: jV In -Tank Gauging Probe. Model: mag W Annular Space or Vault Sensor. Model: 303 Annular Space or Vault Sensor. Model: W Piping Sump / Trench Sensor(s). Model: 208/304 Piping Sump / Trench Sensor(s). Model: Fill Sump Sensor(s). Model: 208/304 Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: j` Mechanical Line Leak Detector. Model: r7 Electronic Line Leak Detector. Model: Veeder Root PLLD j` Electronic Line Leak Detector. Model: 170 Tank Overfill / High -Level Sensor. Model: external alarm Tank Overfill / High -Level Sensor. Model: r Other(specify equipment a and model in Section E on Page 2). Other(specify equipment a and model in Section E on Pae 2). Dispenser 1/2 Dispenser 3/4 ID: ID: jJ Dispenser Containment Sensor(s). Model: 208/304 1v Dispenser Containment Sensor(s). Model: 208/304 W Shear Valve(s). FV_ Shear Valve(s). F Dispenser Containment Float(s) and Chain(s). r Dispenser Containment Float(s) and Chain(s). Dispenser 5/6 Dispenser 7/8 ID: ID: W Dispenser Containment Sensor(s). Model: 2 Dispenser Containment Sensor(s). Model: 208/304 P 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: f7 Dispenser Containment Sensor(s). Model: 208/304 r Dispenser Containment Sensor(s). Model: 208/304 W Shear Valve(s). WO 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): P System set- up r Alarm history report Technician Name (print): Jarrod Cooke Certification No.: 635255 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: 4/24/2013 12/07