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Appendix VI JUN 1.018 (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.waterboards.ca.goy.) MONITORING SYSTEM CERTIFICATION ENVIRONMENTAL t For Use By All Jurisdfcfions Withfn the Stafe of Cafifornfa I IEP�LI" uc-= tTMi i�T Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 96, 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. Generallnformation Facility Name: Vanco Truck — Auto Plaza Site Address: 1033 W Charter Bldg. City: Stockton Zip:95206 Facility Contact Person: Mike Boparai Contact Phone No.: (209)466-0833 Make/Model of Monitoring System: TLS 350 Date of Testing/Servicing: 6/2012018 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: `If the facility contains more tanks or dispensers, copy this form. Include information for every Tank ID: 87 Tank ID: 100 X In -Tank Gauging Probe, Model: MAG X In -Tank Gauging Probe. Model: MAG X Annular Space or Vault Sensor. Model: 409 X Annular Space or Vault Sensor. Model: 409 X Piping Sump / Trench Sensor(s), Model: 208 X Piping Sump /Trench Sensor(s). Model: 208 X Fill Sump Sensor(s). Model: 208 X Fill Sump Sensor(s). Model: 208 X Mechanical Line Leak Detector. Model: LD2000 u Mechanical Line Leak Detector, Model:LD2000 n Electronic Line Leak Detector. Model: U Electronic Line Leak Detector. Model: U n Tank Overfill I High -Level Sensor. Other(specify equipment type and Model model in Section E on Page 2), U U Tank Overfill / High -Level Sensor. Model: Other (specify equipment type and model in Section Eon Tank ID:91 Tank ID: Diesel South X X In -Tank Gauging Probe, Annular Space or Vault Sensor. Model: Model: MAG 409 X X In -Tank Gauging Probe, Annular Space or Vault Sensor. Model: Model: MAG 409 X Piping Sump / Trench Sensor(s). Model: 208 X Piping Sump / Trench Sensor(s), Model: 208 X X Fill Sump Sensor(s). Mechanical Line Leak Detector, Model: Model: 208 LD2000 X n Fill Sump Sensor(s). Mechanical Line Leak Detector. Model: Model: 208 LD2000 U Electronic Line Leak Detector. Model: n Electronic Line Leak Detector, Model: U Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: U Other (specify equipment tpe and model in Section E on Page 2). n Other specify equipment type and model in Section E on Page 2). Dispenser ID: #718 Dispenser ID: %2 X Dispenser Containment Sensor(s), Model:208 X Dispenser Containment Sensor(s). Model: 208 X Shear Valve(s). (OPW) X Shear Valve(s). CI Dispenser Containment Floats and Chain(s). f Dispenser Containment Floats and Chain(s). Dispenser 111 1/4 Dispenser ID: #9/10 X Dispenser Containment Sensor(s). Model: 208 X Dispenser Containment Sensor(s), Model: 208 X U Shear Valve(s). (OPW) Dispenser Containment Floats and Chain(s). X U Shear Valve(s). Dispenser Containment Floats and Chain(s). Dispenser ID: #5/6 Dispenser ID: #11/12 X Dispenser Containment Sensor(s), Model: 208 X Dispenser Containment Sensor(s), Model: 208 X Shear Valve(s). (OPW) X Shear Valve(s). U Dispenser Containment Floats and Chains U Dispenser Containment Floats and Chain(s), tank and dispenser at the facility. C. Certification - I certify that the equipment identified in this document was inspectedlserviced 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 Piot Pian 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): U Syste pupil U (Alarm history report l� Technician Name (print):f tY "N1djj SI— Signature: Certification No.: !VV UU License. No 1001331 Testing Company Name: ELITE IV CONTRACTORS Testing Company Address: 2535 Wigwam Dr Stockton Ca 95205 Monitoring System Certification Page 1 of 4 Phone No.:L209_)_461-6337 _ Date of Testing/Servicing: 12107