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Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at hfp://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: Tracy Municipal Airport Bldg. No.: Site Address: 5749 Tracy Blvd. City: Tracy Facility Contact Person: Ralph Alonzo Contact Phone No.: 209-831-6262 Make/Model of Monitoring System: Veeder Root TLS -300 B. Inventory of Equipment Tested/Certified rharie tha annrnnriata hnxac to ineliratp cnari£r omiinmPnt incnPrtPd /cpmirade Zip: 95377 Date of Testing/Servicing: 8/3/2018 Tank ID: Jet A - JET -A Tank ID: AVAG (8000 gallons) - AVGAS100 In -Tank Gauging Probe. Model: mag r In -Tank Gauging Probe. Model: mag F Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: 794390-420 F Piping Sump / Trench Sensor(s). Model: r Piping Sump / Trench Sensor(s). Model: r Fill Sump Sensor(s). Model: r Fill Sump Sensor(s). Model: r Mechanical Line Leak Detector. Model: r Mechanical Line Leak Detector. Model: r Electronic Line Leak Detector. Model: r Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: flapper r%_0 Tank Overfill / High -Level Sensor. Model: flapper Other(specify equipment a and model in Section E on Pae 2). r Other(specify equipment a and model in Section E on Page 2). Tank ID: AVGAS 100 (4000) - AVGAS100 Tank ID: In -Tank Gauging Probe. Model: mag r In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 794390420 r Annular Space or Vault Sensor. Model: r Piping Sump / Trench Sensor(s). Model: r Piping Sump / Trench Sensor(s). Model: r Fill Sump Sensor(s). Model: r Fill Sump Sensor(s). Model: r Mechanical Line Leak Detector. Model: r Mechanical Line Leak Detector. Model: r Electronic Line Leak Detector. Model: r Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: flapper r Tank Overfill / High -Level Sensor. Model: r Other(specify equipment a and model in Section E on Pae 2). r Other(specify equipment a and model in Section E on Page 2). Dispenser 1 Dispenser ID: ID: Dispenser Containment Sensor(s). Model: 794380-208 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 2 Dispenser ID: ID: r Dispenser Containment Sensor(s). Model: 794380-208 r Dispenser Containment Sensor(s). Model: W Shear Valve(s). r Shear Valve(s). F Dispenser Containment Float(s) and Chain(s). r Dispenser Containment Float(s) and Chain(s). Dispenser 3 Dispenser ID: ID: Dispenser Containment Sensor(s). Model: 794380-208 r Dispenser Containment Sensor(s). Model: 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 intormation for every tanK ana aispenser at the raai¢y. 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 P Alarm history report Technician Name (print): Jarrod Cooke Certification No.: B35255 Testing Company Name: Tanknology Testing Company Address: 11000 N. MoPac Expressway Suite 500 Monitoring System Certification License. No. Signature: 743160 Class 'A' Phone No.: (800) 800-4633 Page 1 of 3 Date of Testing/Servicing: 8/3/2018 12/07