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ago 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 Calilornia 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 lest date. A. General Information VANCO TRUCK&AUTO PLAZA Facility Name: Bldg_No.: Sae Address: 4033 W. CHARTER WAY Chy: STOCKTON Zip: 95205 Facility Comae Person: MIKE Contact Phone No.:( 09 1 466-0833 Make'Model of Monitoring System: VEEDER-ROOT TLS-350 Date of Testing/Servicing: 6/ 28,2016 B. Inventory of Equipment Tested/Certified Check the aegroeriate boxes to indicate specific equipment ins acted/serviced: Tank ID: n1FqFI RQI ITH Tank ID:DIESEL NORTH Lx In-Tank Gauging Probe. Model: vR R4B3giilog x In-Tank Gauging Probe. Model: VR 846396-109 rx Annular Space or Vault Sensor. Model: vR 7nAt o r urn, ,-X Annular Space or Vault Sensor. Model: VR 794390-409 j Piping Sump/Trench Sensor(s). Madel: vR 7g43gn_2oR x Piping Sump/Trench Sensor(s). Model: vR 794390-2oa f,i Fill Sump Sensor(s). Model: VR 794390-208 `x Fill Sump Sensor(s). Model: x Mechanical Line Leak Detector. Model: ymn r In 30pn iy Mechanical Line Leak Detector. Model: viMl I n anon Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: VR 846396-109 x Tank Overfill/High-Level Sensor. Model: VR 846396-109 Other(specify ui ment t and model in Section E on PEE 2. 1-i Other(specity,a ui ment a and model in Section E on Pae 2. Tank to: _ DNI FAnFn A7 Tank ID: gitinn -x In-Tank Gauging Probe. Model: vR a4639a-1o7 In-Tank Gauging Probe. Madel: 396-109 k Annular Space or Vault Sensor. Model: VR 794390-407 IX Annular Space or Vault Sensor. Modell VR 794390407 X Piping Sump I Trench Sensor(s). Model: VR 794390-208 X Piping Sump/Trench Sensor(s). Model:—vR 79439n-2nA Fig Sump Sensor(s). Model: VR 7A439n-208__ LX Fill Sump Sensor(s). Model: uR 784390 2oa Mechanical Line Leak Detector. Model: X Mechanical Line Leak Detector. Model: x_ Electronic Line Leak Detector. Model: VMI 991 mlxm Electronic Line Leak Detector. Model: X Tank Overfill/High-Level Sensor. Model: vR Aeaaoa_+m -.X Tank Overfill/High-Level Sensor. Model: vR e4s396-tm Other(specify ui ent type and model in Section E on Pae 2). _ Other(specify eoubment tvm and model in Section E on Pae 2). Dispenser ID: #1/2 3+1 (DIESEL)WAYNE OVATION Dispenser to: #314 3+1(100-RACING FUEL)WAYNE OVATION X Dispenser Containment Sensor(s). Model: VR 794390-208 x Dispenser Containment Sensor(s). Model: VR 7g4jg. 2na )( Shear Valve(s). X Shear Valve(s). Dispenser Containment Floats and Chains. :i Dispenser Containment Floats and Chains. Dispenses ID: #5163-1 I c )WAYNE OVATION Dispenser to:#7 8 g 10 11 12 13 14-DIESEL WAYNF 590 VISTA X Dispenser Containment Sensor(s). Model: :x Dispenser Containment Sensor(s). Model: X Shear Valve(s). VR 794390-208 x Shear Velvets). Dispenser Containment Floats and Chain(s). Dispenser Containment Floats and Chain(s). DlspenserlD: #151163+1 (DIESEL)WAYNE-PAC PRIDE Dispenser ID: z Dispenser Containment Sensor(s). Model: vR 794390-208 ; Dispenser Containment Semor(s). Model: x Shear ValveM. Shear Valve(s). Dispenser Containment Floats and Chains 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 - 1 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 uipment(((cyyyapagble of generating such reports,I have also attached a copy of the report;(check all that apply): System set-up a rm hist ry rt Technician Name(print): FRED BABEL Signature 17Q. Certification No.: VR 835723/ICC 00025547 Lice e.No.: 1001331 A-HAZ Testing Company Name: ELITE IV CONTRACTORS Phone No.: 20( 9 1 461-6337 Testing Company Address: 2535 WIGWAM OR Date of Testing/Servicing: D6/19/ 16 lzO Monitoring System Certification Page 1 of 4 12107 1 2/21107