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Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at httP://www waterboards.ca. ov.) 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 ownerloperator. 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: AG Soanys Jet Center Bldg.No.: Site Address: 48.00 S Airport Ave City: Stockton.CA Zi 95206 — P Facility Contact Person: Thomas Tilled Contact Phone No.:(2091 982-1550 Make/Model of Monitoring System: Veeder Root TLS 350 Dale of Testing/Servicing: Febru_a y 29 2012 B. Inventory of Equipment Tested/Certified Check the aeEropriate boxes to indicates ecific equipment ins ectadlserviced: Tank ID: #3 Jet A Tank ID: #4 Jet A x In-Tank Gauging Probe. Model:M1 x In-Tank Gauging Probe. Model:Mag i x Annular Space or Vault Sensor. Model:420 x Annular Space or Vault Sensor. Model:409 x Piping Sump l Trench Sensor(s). Model:208 x Piping Sump 1 Trench Sensor(s). Model:208 Fill Sump Sensor(s). Model: n Fill Sump Sensor(s). Model: x Mechanical Line Leak Detector. Model:FXIV D x Mechanical Line Leak Detector. Model: FXIV D n Electronic Line Leak Detector. Model n Electronic Line Leak Detector, Model: L1 Tank Overfill 1 High-Level Sensor. Model: Tank Overfill!High-level Sensor. Model: Other(specifyequipment t e and model Vn Section E on Page 2). ❑ Other s eci a ui equipment t e and model in Section E an Page 2. Tank ID: #5 Jet A Tank ID; x In-Tank Gauging Probe. Model:MacLl i I In-Tank Gauging Probe. Model: x Annular Space or Vault Sensor. Model:409 Annular Space or Vault Sensor. Model x Piping Sump 1 Trench Sensor(s). Model 208 1 Piping Sump i Trench Sensor(s). Model: I, Fill Sump Sensor(s). Model i Fill Sump Sensor(s). Model: x Mechanical Line Leak Detector. Model:LD 3000 High Flow Mechanical Line Leak Detector, Model: I Electronic Line Leak Detector. Model: 7 Electronic Line Leak Detector. Model: i Tank Overfill/High-Level Sensor. Model: Tank Overfill I High-Level Sensor. Model L Other(specify equipment t e and model in Section E on 12). 1 ❑ Other(specify equipment t e and model in Section E on Page 2). Dispenser ID: JetA Trans Sumo Dispenser ID: Fill Filter Sump I Shear Valve(s). x Dispenser Containment Sensor(s). Model:0794380-208 x Dispenser Containment Sensor(s). Model: 0794380-208 � Shear Valve(s). Dispenser Containment Floats and Ghain s. Dispenser Containment Floats and Chain(s), Dispenser ID:Jet A Trans ani Dispenser ID:7&8 x Dispenser Containment 5ensor(s). Model:0794380-266 Dispenser Containment Sensor(s). Model: Shear Valve(s), rl Shear Valve(s). I Dispenser Containment Floats and Chains. i._ Dispenser Containment Floats and Chains. Dispenser ID: Dispenser ID: Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: C Shear Valve(s). a Shear Valve(s). Dispenser Containment Floats and Chains I i Dispenser Containment Floats and Chains. '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;(check all that apply): System set-up :I Alarm history report Technician Name(print): Benjamin F.Duncan Jr Signature: r, - isusy Certification No.: A23152 License. No,:90-1120 Testing Company Name:R&D Compliance Testing Phone No.: (7071 821-0378 Testing Company Address: P.O. Box 1503 Ukiah Cafif.95482 Date of Testing/Servicing: 2/29/2012 Monitoring System Certification Page 1 of 4 12'07 1 2/21/07