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• Appendix VI VLI Y E 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 Regul$04 3 2015 This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be prWRONMENTAL each monitoring system control panel by the technician who perform$the work.A copy of this form must be provided to the tan( owner/operator.The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of teg l ft TW f1FOAOT"MIT A. General Information Facility Name: CHARTER WAY CHEVRON Bldg.No.: Site Address: 508 W CHARTER WAY City: STOCKTON Zip: Facility Contact Person: RINKU Contact Phone No.: (209)465.3440 Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 10-23-15 B. Inventory of Equipment Tested/Certified Check the ageropriate boxes to indicates ecific equipment Ins ectad/serviced: TanklD: 87 TanklD: 87 ® In-Tank Gauging Probe. Model: MAG 1 ® In-Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 420 ® Annular Space or Vault Sensor. Model: 420 ® Piping Sump/Trench Seasons). Model: 208 ® Piping Sump/Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: PLLD ® Electronic Line Leak Detector. Model: PLLD ® Tank Overfill/High-Level Sensor. Model: FLAPPER ® Tank Overfill/High-Level Sensor. Model: FLAPPER ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). Tank ID: 91 TanklD: ® In-Tank Gauging Probe. Model: MAG 1 ❑ In-Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 420 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump/Trench Sensor(s). Model: 208 ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Seasons). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: PLLD ❑ Electronic Line Leak Detector. Model: ® Tank Overfill/High-Level Sensor. Model: FLAPPER ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). Dispenser ID: 1-2 Dispenser ID: 3.4 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ® Shear Velvets). ® Shear Valve(s). ® Dispenser Containment Float(s)and Chain(s). ® Dispenser Containment Floats)and Chain(s). Dispenser ID: 5=6 Dispenser ID: 7-8 ❑ Dispenser Containment Sensors). Model: ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ® Shear Valve(s). ® Dispenser Containment Float(s)and Chain(s). ® Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: Sensor(s). Model: ❑ Shearvalve(s). ❑Shear Valve(s). ❑ Dispenser containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chairl '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 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 equipment capable of generating such reports,1 have also attached a copy of the report;(check all that apply): ❑System set-up ❑Alarm history report Technician Name(print): FELIX RAMIREZ Signature: ,ash—j'__-> Certification No.: 5273934-UT License No: 08-1740 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 2n"STREET GALT CA 95632 Date of Testing/Servicing: 10-23-15 Monitoring System Certification Page 1 of 4 2/21/07