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Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www,waterboards.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: Vanco Truck —Auto Plaza Site Address: 1033 W Charter Facility Contact Person: Mike Boparai_ Make/Model of Monitoring System: TLS 35 B. Inventory of Equipment Tested/Certified Bldg. No.: City: Stockton Zip:95206 Contact Phone No.: (209)466-0833 Date of Testing/Servicing: 6/20/2018 *If the facility contains more tanks or dispensers, copy this form. Include information for every Check the appropriate boxes to indicate specific equipment inspectedlserviced: Tank ID: Diesel North Tank ID: 11 In -Tank Gauging Probe. Model: X In -Tank Gauging Probe, Model: MAG X Annular Space or Vault Sensor, Model: 409 a Annular Space or Vault Sensor. Model: X Piping Sump / Trench Sensor(s). Model: 208 U Piping Sump /Trench Sensor(s). Model: X X Fill Sump Sensor(s). Mechanical Line Leak Detector. Model: 208 Model: LD2000 1:1 ❑ Fill Sump Sensor(s). Mechanical Line Leak Detector. Model: Model: u Electronic Line Leak Detector. Model: I I Electronic Line Leak Detector, Model: 0 U Tank Overfill / 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 t e and model in Section E on Page 2). TankiD: TankiD: 0 In -Tank Gauging Probe. Model: u In -Tank Gauging Probe, Model: 0 Annular Space or Vault Sensor. Model: U Annular Space or Vault Sensor. Model: 0 Piping Sump / Trench Sensor(s). Model: L Piping Sump / Trench Sensor(s), Model: 0 Fill Sump Sensor(s). Model: U Fill Sump Sensor(s). Model: Fl Mechanical Line Leak Detector, Model: U Mechanical Line Leak Detector. Model: n Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: n Tank Overfill ! High -Level Sensor. Model: 0 Tank Overffll / High -Level Sensor. Model: 0 Other specify equipment type and model in Section E on Page 2), 0 Other specify equipment type and model in Section E on Page 2). Dispenser ID: #13/14 Dispenser ID: X Dispenser Containment Sensor(s). Model:208 a Dispenser Containment Sensor(s), Model: X Shear Valve(s). (OPW) 0 ShearValve(s). 0 Dispenser Containment Floats and Chain(s). U Dispenser Containment Floats and Chain(s), Dispenser ID: #15/16 Dispenser ID: X Dispenser Containment Sensor(s). Model: 208 ❑ Dispenser Containment Sensor(s), Model: X Shear Valve(s). (OPW) 0 Shear Valve(s). rt Dispenser Containment Float(s) and Chain s . 0 Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser 10: [:I Dispenser Containment Sensor(s). Model: n Dispenser Containment Sensor(s). Model: () Shear Valve(s). (OPW) n Shear Valve(s). r_I Dispenser Containment Floats and Chains it Dispenser Containment Floats and Chains . C. Certification - I certify that the equipment identified in th tank and dispenser at the facility. s 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 and a Plot Plan showing the layout of monitoring equipment. copy of the report; (check all that apply): ❑ System se -i p Technician Name (print): Ltir f i(�I Signature: -m K Certification No.: I(lrQa (��I information is correct For any equipment capable of generating such reports, I have also attached a n Alarm history report 1.6337 License. No.: 1001331 A-HAZ Testing Company Name: ELITE IV CONTRACTORS Phone No.:L209_)_46___„ Testing Company Address: 2535 Wigwam Dr Stockton Ca 95205 Date of Testing/Servicing: 1/11)/ Monitoring System Certification Page 1 of 4 12107