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1. Appendix VI ..i (Copies of Monitoring System Certification form and UST Monitoring Plot flan available athttD•//www swrb.caaov) MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the Iuatc of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 76,Division 3, Title 23,California Code of Regulations This form must he used to document testing still servicing of monitoring equipment. A separate certification or report must be prepared for each monitoring system control by the technician who performs the work. A copy or this form must be provided to the tank system owner/operetor. 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: Estes Trucking Bldg.No.: Site Address: 7611 S. Airport Way City: Stockton Zip 95206 Facility Contact Person: Mark Hancock and Jim Bunck Contact Phone No,: 714.893.6140 Make/Model of Monitoring System: Veeder-Root TLS 350 Date of Testing/Servicing: May 17 2010 B. Inventory of Equipment'Tested/Certified Fmn a to riate hases to Indicates eeine a of ment inspected/serviced: 01 DIESEL Tank ID:k Onuging Probe. Model: Mag Probe M In•Tank Uauging Probe. Model:lar Space or Vault Sensor, Model: VR 302 O Annular Space or Vault Sensor. Model:Sump/1'mnch Sensor(s). Model: VR 208 ❑ Piping Sump/'1'rcnch Sensnr(s). Model:mp Sensor(s). Model: ❑ Fill Sump Serrsor(s). Model:anical Line Leek Detector. Model: F�Petro MLD Diesel ❑ Mechanical Line Leak Uctcctor. Model: nie Line Leak Detector. Model: Q Electronic Line Leak Detector. Model: 13 'Tank Overfill/Nigh-Level Sensor. Model: , ,_ ❑ 'Tank Ovcrrill/High•l.evel Sensor. Model: 0 Others ecif ui menit e and model in Scetion B on Pae 21. ❑ Other(specify equipment type and model in Section F on Page 2). 'rank ID: 02 Tank ID: ( )In-Tank Gauging Probe. Model: 0 In=rank Gauging Probe. Model: Annular Sparc or Vault Sensor. Model: 0 Annular Space or Vault Sensor. Model: Piping Sump/'french Sensor(s). Model_ _ O Piping Sump/Trench Sensor(s) Model: _ I:] Fill Sump Sensor(s), Model: 0 FIII Sump Sensor(s). Model: LJ Mechanical Line Lusk Detector. Model: _ 0 Mechanical Linc Leak Detector. Model:......-, LI l;iectronic Linc Leak Detector. Model:_ 0 HiwtmLeak Line DcW— or. MudeL ❑ Tank Overfill/I1191ALcvcl Sense.•. Model: __ 13 Tank Overfill/High-Level Sensor. Model: ❑ (liber s ecif c ulpment t e and model in Section E on Pae 2).` ❑ Other�speclfy a ui mcnl type and model in Soctinn F.:on Dispenser ID:--it I ai Dispenser 1D: ODispenserComalnmemScoscr(s). Model: _ „_ ❑ Dispenser ContainmunlSensor(s). Model: Shear Valvc(s). El Shear Valve(s). (x)Dispenser Containment Float(s)and Chain (s).Bravo 0 Dis eraser Containment Float s and Chain s . Dispenser ID; Dispenser ID-. _ _..... Dispenser Containment Scnsor(s). Model: ❑ Dispenser Containment.Sensor(s). Model:._,,..__. Shear Valve(s). 0 Shear Valve(s). M Dispenser Containment Floats)and Chal%s). ❑ Dispenser Cuntainment Floats)and Chain s), Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensur(s) Model: Q Dispenser Containment Sensor(s). Model: _ Shear Valvc(s), 0 Shear Volve(s), UDisrienser Containment Floatl and Chain 3 . 1 13 Dis enser Containment Float(sl.nod 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 -I certlly that the equipment identified In this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached M this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is cnrrect and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attached a copy or the report;(check all that apply): ( )System set-up ( ) Alarm history report '1'echnician Name(print): Cric Mol) K acrd Signature: Eric ;MaCgaczvd Certification No.: TCC Tech 525020007 VIR A27995 Licamse Nn.: 309105 Testing Company Name;STOCwrON SERVICE STATION EQUIPMF,NT CO.INC. Phone No 2()9-464-8333 '1'esting Company Address: 808 N.Union Street,Stockton,CA 952054152 Date of I'esting/Servicing: May 17,2010 Monitoring System Certification Page I or3 12/117