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(Copies of Monitoring System Certification MONITOI For Use Authority Cited., Chapter 6.7, Health and Regulations This form must be used to document testing and servicing of in system control panel by the technician who performs the work owner/operator must submit a copy of this form to the local a( A. General Information Facility Name: CHEVRON 210997 (N-4693) Site Address: 1442A COLONY DR. Facility Contact Person: PATTY Make/Model of Monitoring System: Veeder Root TLS -350 B. Inventory of Equipment Tested/Certified rhu' tFu nnnn.nrioro Annie m rnAh—tv cno,inr an,unmonr RECEIVED M ED Appendix VI C[B 2 2 2016 n and GST Monitoring Plot Plan available at http://wv�nv.swrcb.ca.go .} G SYSTEM CERTIFICATION ENVIRONMENTAL Jurisdictions Within the State of California y Code; Chapter 16, Division 3, TItle 23, California LWMIP nFpggTll mitoring equipment. A separate certification or report must be prepared for each monitoring A copy of this form must be provided to the tank system owner/operator. The :ncy regulating UST systems within 30 days of test date. City: RIPON Contact Phone No.: 209-599-0149 Bldg. No.: Zip: 95366 Date of Testing/Servicing: 1/21/2016 Tank ID: T1:SUPREME UNLEADED -PREMIUM r In -Tank Gauging Probe. Model: maq r Annular Space or Vault Sensor. Model: 409 r. Piping Sump / Trench Sensor(s). Model: 209 r Fill Sump Sensor(s). Model: 209 rMechanical Line Leak Detector. Model r Electronic Line Leak Detector. Model: Veeder Root PLLD r Tank Overfill / High -Level Sensor. Model: flapper/ext alarm Other (soecifv equipment t e and model in Section E on Pa Tank ID: T2:REGULAR UNLEADED - REGULAR r In -Tank Gauging Probe. Model: maq r Annular Space or Vault Sensor. Model: 409 r Piping Sump / Trench Sensor(s). Model: 209 r Fill Sump Sensor(s). Model: 209 r Mechanical Line Leak Detector. Model: r Electronic Line Leak Detector. Model: Veeder Root PLLD V, Tank Overfill / High -Level Sensor. Model: Flapper/eat alarm r Other (specify equipment a and model in Section Eon Pae 2), 2). Tank ID: r In -Tank Gauging Probe. Model: r Annular Space or Vault Sensor. Model: r Piping Sump / Trench Senspr(s). Model: r Fill Sump Sensor(s). Model: r Mechanical Line Leak Detector. Model: r Electronic Fine Leak Detector. Model: _ Tank Overfill / High -Level Sensor. Model: Other s eci a ui ment type and model in Section E on Pa Tank ❑ ❑ ❑ --I r7 ID: In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Une Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor, Model: Other(specify equipment a and model in Section E on Pae 2). 2). Dispenser 1/2 ID: r Dispenser Containment Sensor(s). Model: 209 r Shear Valve(s). r Dispenser Containment Floi and Chain(s). Dispenser 3/4 ID: r Dispenser Containment Sensor(s). Model: 209 r Shear Valve(s). r Dispenser Containment Floats and Chain(s). Dispenser 5/6 ID: r Dispenser Containment Sensor(s). Model: 209 r Shear Valve(s). rj Dispenser Containment Float(s) and Chain(s). Dispenser 7/8 ID: r Dispenser Containment Sensor(s). Model: 209 r Shear Valve(s). r Dispenser Containment Float(s) and Chairi Dispenser 9/10 ID: C Dispenser Containment Sensor(s). Model: 209 Shear Valve(s). rj Dispenser Containment Floats) and Chain(s). Dispenser 11/12 ID: r Dispenser Containment Sensor(s). Model: 209 r Shear Valve(s). r Dispenser Containment Floats and Chain(s). *If the facility contains more tanks or dispensers, copy this torte. 1tICIWe information ter every tank ana a6penser at me facility. C. Certification- I certify that the equipment identified in this clocurnent was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e.g. manufactures 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 s ch reports, I have also attached a copy of the report; (check all that apply): r.. System set- up Pill Alarm history report Technician Name (print): Jarrod Cooke Certification No.: 835255 Testing Company Name: Tanknology Testing Company Address: 11000 N. MoPac Monitoring System Certification Suite Signature: No.: 74316001 Phone No.: (800)800-0633 Date of Testing/Servicing: 121/2016 if 3 12/07