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Appendix VIj` _EIVC[ (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.swrcb.L TJ C MONITORING SYSTEM CERTIFICATION MAR 0 4 2015 For Use By All Jurisdictions Within the State of California Authority Cited:Chapter 6.7,Health and Safety Code;Chapter 16,Division 3, Tllle 23,CallfornMOR NMENTA+ Regulallons This form must be used to document testing and servicing of monitoring equipment A separate certillution 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 ropy of this form to the local agency regulating UST systems within 30 days of test date. A.General Information Facility Name: TRACY PETRO Bldg.No.: Site Address: 3400 N.MACARTHUR DR City: TRACY Zip: 95376 Facility Contact Person: KARAM SINGH Contact Phone No.: 209-814-Ml Make/Model of Monitoring System: Veeder Root TLS-350 Date of Testing/Servicing: 2/27/2015 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/servictld: Tank ID: Tl-PREMIUM Tank ID: T2-REGULAR r In-Tank Gauging Probe. Model: mag r In-Tank Gauging Probe. Model: mag r Annular Space or Vault Sensor. Model: 303 r Annular Space or Vault Sensor. Model: 373 r Piping Sump/Trench Sensor(s). Model: 208 r Piping Sump/Trench Sensor(s). Model: 208 V Fill Sump Sensor(s). Model: 208 r Fill Sump Senwr(s). Model: 20B r Mechanical Line Leak Detector. Model: Vaporless LD-2000 r Mechanical Line Leak Detector. Model: Vaporless LD-2000 r Electronic Line Leak Detector. Model r Electronic Line Leak Detector. Model: r Tank Overfill/High-Level Sensor.Model: ext alarm r Tank Overfill/High-Level Sensor.Model: ext alarm Other(specify equipment ify equipment and model in Section E on Pae 2). Tank ID: T3-Diesel Tank ID: r In-Tank Gauging Probe. Model: mag r In-Tank Gauging Probe. Model: r Annular Space or Vault Sensor. Model: 303 r Annular Space or Vault Sensor. Model: V Piping Sump/Trench Sensor(s). Model: 208 r Piping Sump/Trench Sensor(s). Model: r Fill Sump Sensor(s). Model: 208 r Fill Sump Sensor(s). Model: r Mechanical Line Leak Detector. Model: Vaporless LD-2000 r Mechanical Line Leak Detector. Model: r Electronic Line Leak Detector. Model: r Electronic Line Leak Detector. Model: r Tank Overfill/High-Level Sensor.Model: 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: r Dispenser Containment Sensor(s).Model: 208 r Dispenser Containment Sensor(s).Model: 208 r Shear Valve(s). r Shear Valve(s). Dispenser Containment Floats and Chain(s). r Dispenser Containment Floats and Chain(s). Dispenser 5/6 Dispenser 718 ID: ID: r Dispenser Containment Sensor(s).Model: 208 r Dispenser Containment Sensor(s).Model: 208 r Shear Valve(s). r Shear Valve(s). r Dispenser Containment Floats and Chain(s). Dispenser Containment Floats and Chain(s). Dispenser Dispenser ID: ID: r Dispenser Containment Senwr(s).Model: r Dispenser Containment Senwr(s).Model: r Shear Valve(s). r Shear Valve(s). Dispenser Containment Float(s)and Chain(s). Dispenser Containment Floats 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 appWJ:r System set- up r Alarm history report Technician Name(print): Jarrod Cooke Signature: Certification No.: 835255 License.No.: 743160 Class'A' Testing Company Name: Tanknology Phone No.: (80))800-4633 Testing Company Address: 11000 N.MoPac Expressway Suite 500 Date of Testing/Servicing: 2/27/2015 Monitoring System Certifrcatlon Page 1 of 3 12/07