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Page 1/3 Appendix VI MONITORING SYSTEM CERTIFICATION ' i t%;7 0� 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 7 each monitoring system control panel by the technician who performs the work.A copy ofthis forth must be provided tothe 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: =L v i1t ;,;;t,�mv HEALTH Facility Name: CJS CHEVRON Bldg.No.: WCES Site Address: 7501 11 T"STREET City: TRACY CA Zip: Facility Contact Person: Contact Phone No.: ( ) Make/Model of Monitoring System: TLS 350 Date of Testing/Servicing: 1 211 6f 20 1 5 B. Inventory of Equipment Tested/Certified Check the approprWe boxes to Indicate SIDSCIfIC equipment Ins ected/serviced: Tank ID: 87 Tank Size: Tank ID: 91 Tank Size: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ®Annular Space or Vault Sensor. Model: 420 ($Annular Space or Vault Sensor. Model: 420 ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ FII Sump Sensor(s). Model: ❑ FII Sump Sensor(s). Model: ❑ Mechanical Una Leak Detector. Model: ❑ Mechanical Una Leak Detector. Model: ❑ Electronic Una Leak Detector. Model: ❑ Electronic Une Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify,equipment type and model in Section E on Pogo 2). ❑ Other(specify equipment type and model in Section E on Page 2). Tank ID: DIE Tank Size: Tank ID: Tank Size: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ®Annular Space or Vault Sensor. Model: SPLIT IN 91 ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ FII Sump Sensor(s). Model: ❑ FII Sump Sensor(s). Model: ❑ Mechanical Una Leak Detector. Model: ❑ Mechanical Una Leak Detector. Model: ❑ Electronic Una Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(sped equipment fy type and model in Section E on Page 2). Dispenser ID: 1-2 Dispenser ID: 7-8 ® Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model: 208 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Floats)and Chain(s). Dispenser ID: 34 Dispenser ID: TRANS SUMP ® Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model:208 ® Shear Valve(s). ❑ Shear Vallo(s). ❑ Dispenser Containment Floats)and Chain(s). ❑ Dispenser Containment Floats)and Chain(s). Dispenser ID: 5.6 Dispenser ID: ❑Dispenser Containment ® Dispenser Containment Sensor(s). Model: 208 Sensor(s). Model: ® Shear Valve(s). ❑Shear Valve(s). ❑ Dispenser Containment Floats)and Chain(s). ❑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 Inspectediserviced 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;(ckeckatrrkarapp(p): ❑System set-up ❑Alarm history report Technician Name(print): David Winkler Signature: Certification No.: 5263373-UT License No: 008-1739 Testing Company Nems: AFFORDA-TEST Phone No. (209)7440112 Testing Company Address: 416 2 STREET GALT CA 95632 Date of TestinglServicing: Monitoring System Certification Page 1 of 3 2/21/07