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Is Appendixvi FEB 17 2015 (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at hitp:/AVwW-svvrob.ca.gov,) MONITORING SYSTEM CERTIFICATION NT AuthorityFor Use By AllJunsdictfons Within the State OfCalifomia N� IRONMENTAI Regulations Cited: For 6.7,Health and Safety Code;Chapter 16,Division 3, 77l/e 23,Cal/forn/a•Code of�, T Regulat/ons This form must be used to document testing and servicing of monitoring equipment.A separate cemficabon 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 test date. A.General Information Facility Name: CORNER STORE#3698 Site Address: 153 E 11TH STQC-0-3 Bldg.No.; Facility Contact Person: MGR-CHELA City: TRACY Zip: 95375 Make/Model of Monitoring System: Veeder Root TLS 350 Contac[Phone No.: 209-832-8815 B.Inventory Check the a of ro u to bo>cesresteto Intl cafe specific ui rent ins Date of Testing/Servicing: 1/28/2015 Tank ID: TS-UNLEADED d serviced: r In-Tank Gauging Probe. Model: ma Tank ID: T2-UNLEADED P Annular Space or Vault Sensor. Model: 420 r In-Tank Gauging Probe. Model: maq W Piping Sump/Trench Sensor(s). Model: 2—� r Annular Space or Vault Sensor. Motlel; 420 r Fill Sump Sensor(s). �_ r Piping Sump/Trench Sensor(s). Model:Model: 208 r Mechanical Une Leak Detector. Model: Red Jacket�FX1y— r Fill Sump Sensor(s). Model: I Electronic Line Leak Detector. Model:—� r Mechanical Line Leak Detector. Model: r Tank Overt 11/High-Level Sensor.Model: e/a r Electronic Line Leak Detector, Model: Others d e ui ment and model m Section E o� n p� r Tank Overfill/High-Level Sensor.Model: e/a Other s d e ui ment a and model in Section ESection E o�— Tank ID: T3-PREMIUM Tank ID: V In-Tank Gauging Probe. Model: moo P,Annular Space or Vault Sensor. Model: 42Q r In-Tank Gauging Probe. Model.. Piping Sump/Trench Sensor(s). Model:— r Annular Space or Vault Sensor. Model: r Fill Sump Sensor(s). Model: r Piping Sump/Trench Sewo(s). Model: �_ r Fill Sump Senscr(s). Model:-- r Mechanical Une Leak Detector. Model: Red Jacket F%IV r Mechanical Line Leak Detector. Madel: r Electronic Line Leak Detector. Model:_= r Tank Overfill/High-Level Sensor.Model: e/a r Electronic Une Leak Detector. Model .Other s eci a ui ment and model in Section E on Pae 2. r Tank OtherOverfill s a ci /e High menti Sensor,andmodelin Section E o� n p Dispenser 1/2 type ID: Dispenser 3/4 ID: r Dispenser Containment Sensor(s).Model; r Dispenser Containment Sensor(s).Model; r Shear Valve(s). r Shear Valve(s). r Dis riser Containment Float s)and Chain s). r Dispenser Containment Floats and Chain s). Dispenser 5/6 Dispenser ID: Iis r Dispenser Containment Sen or(s).Model r Dispenser Containment Sensor(s),Model: V Shear Valve(s). r Shear Valve(s). W Dispenser Containment Float(s)and Chain s). r Dispenser Containment Float s)and Chain s. Dispenser Dispenser 1D: ID: (� Dispenser Containment Sertsor(s).Motlel: r Dispenser Containment Sensor(s).Model: r Shear VaNe(s). r Shear Valve(s). r Dispenser Containment Float(s)and Chain(s). I r 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 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 momtomtg equipment.For any equipment capable of generating such reports,I have also attached a copy of the report;(check all that apply)r System set- up r Alarm history report Technician Name(print): Brent Bowen Signature: Certification No.: 042B15 Ucense.No.: 743160 Class'A' Testing Company Name: Tanknology Phone No.: (800)800-4633 Testing Company Address: 11000 N.MoPac Expressway Suite 500 Date of Testing/Servicing: 1/28/2015 Monitoring System Certification Page 1 of 3 12/07