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Appendix VI <br /> (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.swrcb.ca.gov.) <br /> MONITORING SYSTEM CERTIFICATION <br /> For Use By All Jurisdictions Within the State of California <br /> Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3,Title 23, California Code of <br /> Regulations <br /> This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be prepared for each monitoring <br /> 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 <br /> owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. <br /> A.General Information <br /> Facility Name: Fed Ex Ground Bldg. No.: <br /> Site Address: 120 S Hansen Road City: Tracy Zip: 95304 <br /> Facility Contact Person: Jessie Andrada Contact Phone No.: 916-826-3081 <br /> Make/Model of Monitoring System: Veeder Root TLS-350 Date of Testing/Servicing: 8/17/2016 <br /> B.Inventory of Equipment Tested/Certified <br /> Check the appropriate boxes to indicatespecific equipment ins ected/serviced: <br /> Tank ID: T-1-Diesel Tank ID: T-2-Diesel <br /> F/ In-Tank Gauging Probe. Model: mag F7 In-Tank Gauging Probe. Model: mag <br /> W Annular Space or Vault Sensor. Model: 303 F470 Annular Space or Vault Sensor. Model: 794380-303 <br /> FV Piping Sump/Trench Sensor(s). Model: 208/304 F Piping Sump/Trench Sensor(s). Model: 208/304 <br /> FV Fill Sump Sensor(s). Model: 208/304 Fill Sump Sensor(s). Model: 208/304 <br /> F Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: <br /> r7 Electronic Line Leak Detector. Model: Veeder Root PLLD- Electronic Line Leak Detector. Model: <br /> FV Tank Overfill/High-Level Sensor.Model: flapper/ext alarm FV Tank Overfill/High-Level Sensor.Model: flapper/ext alarm <br /> F Other(specify equipment t e and model in Section E on Page 2). F Other(specify equipment t e and model in Section E on Page 2). <br /> Tank ID: T-3-Biodiesel Tank ID: <br /> In-Tank Gauging Probe. Model: mag r In-Tank Gauging Probe. Model: <br /> 170 Annular Space or Vault Sensor. Model: 794380-303 Annular Space or Vault Sensor. Model: <br /> F7 Piping Sump/Trench Sensor(s). Model: 208/304 Piping Sump/Trench Sensor(s). Model: <br /> r Fill Sump Sensor(s). Model: 208/304 r Fill Sump Sensor(s). Model: <br /> Mechanical Line Leak Detector. Model: r Mechanical Line Leak Detector. Model: <br /> Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: <br /> r7 Tank Overfill/High-Level Sensor.Model: flapper/ext alarm Tank Overfill/High-Level Sensor.Model: <br /> r— Other(specify equipment t e and model in Section E on Page 2). Other(specify equipment t e and model in Section E on Page 2). <br /> Dispenser 1 Dispenser 5/6 <br /> ID: ID: <br /> r Dispenser Containment Sensor(s).Model: 208/304 FV Dispenser Containment Sensor(s).Model: 208/304 <br /> F7 Shear Valve(s). Shear Valve(s). <br /> r— Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). <br /> Dispenser 7/8 Dispenser 1 SAT/2 <br /> ID: ID: <br /> F7 Dispenser Containment Sensor(s).Model: 208/304 FV Dispenser Containment Sensor(s).Model: 208/304 <br /> W Shear Valve(s). P Shear Valve(s). <br /> F Dispenser Containment Float(s)and Chain(s). F Dispenser Containment Float(s)and Chain(s). <br /> Dispenser 2 SAT/3 Dispenser 3 SAT/4 <br /> ID: ID: <br /> F7 Dispenser Containment Sensor(s).Model: 208/304 r Dispenser Containment Sensor(s).Model: 208/304 <br /> W Shear Valve(s). Shear Valve(s). <br /> r Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). <br /> *If the facility contains more tanks or dispensers,copy this form.Include information for every tank and dispenser at the facility. <br /> C.Certification-I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers'guidelines.Attached to <br /> this Certification is information(e.g. manufacturers'checklists)necessary to verify that this information is correct and a Plot Plan showing the layout of <br /> monitoring equipment. For any equipment capable of generating such reports,I have also attached a copy of the report; (check all that apply): W System set- <br /> up r Alarm history report <br /> Technician Name(print): Jarrod Cooke Signature: <br /> Certification No.: B35255 License. No.: 743160 Class'A' <br /> Testing Company Name: Tanknology Phone No.: (800)800-4633 <br /> Testing Company Address: 11000 N. MoPac Expressway Suite 500 Date of Testing/Servicing: 8/17/2016 <br /> Monitoring System Certification Page i of 3 12/07 <br />