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r Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http:l/www.waterboards.ca.gov.) MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority Cited. Chapter 6.7, Health and Safety Code; Chapter 96, 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 owner/operator. The ownerloperator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information RECEIVED Facility Name: FAST AND EASY Bldg. Na.: Site Address: 10878 N. HWY 99 Facility Contact Person: MIKEALE City: STOCTON CA, Zip: 95212 Contact Phone No.: MAY 18 2 015 Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of TestinglServicing: 4/2212015 A�i■ ENVjROC�► T i B. Inventory of Equipment Tested/Certified ENVIRONMENTAL H n YP�APT A;:NT Check the appropriate boxes to indicatespecific equipment inspectediserviced: Tank ID: 1 SUPREME Tank ID: UNLEADED X In -Tank Gauging Probe. Model: VR MAG PROB X In -Tank Gauging Probe. Model: VR MAG PROB X Annular Space or Vault Sensor. Model: VR 420 X Annular Space or Vault Sensor. Model VR 420 X Piping Sump / Trench Sensor(s). Model: VR 208 X Piping Sump / Trench Sensor(s). Model: VR 208 Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: X Mechanical Line Leak Detector. Model: RED JACKET FXIV X Mechanical Line Leak Detector. Model: RED JACKET FXIV Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill 1 High -Level Sensor. Model: Tank Overfill / High -Level Sensor. Model: Other (specify equipment a and model in Section E on Page 2). Other (specify equipment t e and model in Section E on Page 2). Tank ID:2 PREMIUM*2 Tank ID: DIESEL X In -Tank Gauging Probe. Model VR MAG PROB X In -Tank Gauging Probe. Model: VR MAG PROB X Annular Space or Vault Sensor. Model: VR 420 X Annular Space or Vault Sensor. Model: VR 420 X Piping Sump / Trench Sensor(s). Model: VR 208 X Piping Sump i Trench Sensor(s). Model: VR 208 Fill Sump Sensor($). Model: _ Fill Sump Sensor(s). Model: X Mechanical Line Leak Detector. Model: VMI LD 2000 X Mechanical Line Leak Detector. Model: RED JACKET FXIV _ Electronic Line Leak Detector. Model: - Electronic Line Leak Detector. Model: _ Tank Overfill 1 High -Level Sensor. Model: a Tank Overfill 1 High -Level Sensor. Model: Other (specify equipment a and model in Section E on Page 2). u Other (specify equipment t e and model in Section E on Pae 2). Dispenser ID: 1/2 Dispenser ID: 718 Dispenser Containment Sensor(s). Model: 1 i Dispenser Containment Sensor(s). Model: Shear Valve(s). i i Shear Valve(s). X Dispenser Containment Floats and Chain(s). BROVO X Dispenser Containment Floats and Chain(s). BROVO Dispenser ID: 314 Dispenser ID: 9110 - Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: _, Shear Valve(s). - Shear Valve(s). X Dis enser Containment Floats and Chain(s). BROVO Dispenser Containment Floats and Chain(s). Dispenser ID: 5/6 Dispenser ID: ._ Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). X Dispenser Containment Floats and Chains BROVO Dispenser Containment Floats and 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 certify that the equipment identified in this document was inspectedlserviced 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 Ala ory report Technician Name (print): JASON HAASE Signatu Certification No.: 840970 License. No.: 9209 5 Testing Company Name: MID VALLEY CONSULTING Phone No.:(530) 74 -9892 Testing Company Address: 1097 BRONCO DRIVE, PLUMAS LAKE, CA 95961 Date of Testing/Servicing: 4/22/2015 Monitoring System Certification Page 1 of 4 12107 2/21/07