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*40 RECEIVED Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://W Wwr 1AT"9H_% MONITORING SYSTEM CERTIFICATION For Use By All Junsdictions Within the State of California ENVIRONMENTAL Authorlty Cited:Chapter 6.7, Health and Safety Code;Chapter 16, Division 3, Title 23, id(Fft 196 4TYPT 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 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: YRC 813 Bldg. No.: Site Address: 1535 E PESCADERO AVE City: TRACY Zip: 95304 Facility Contact Person: KRIS/ROY Contact Phone No.: 209993-7946 Make/Madel of Monitoring System: Veeder Root tis 350 Date of Testing/Servicing: 3/8/2013 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific eaulpment in serviced: Tank ID: waste oil near rack-WASTE OIL Tank ID: waste oil near gate-WASTE OIL P In-Tank Gauging Probe. Model: mag r In-Tank Gauging Probe. Model: WO Annular Space or Vault Sensor. Model: 303 P Annular Space or Vault Sensor. Model: 303 PO Piping Sump/Trench Sensor(s). Model: 205 PO Piping Sump/Trench Sensor(s). Model: 205 F Fill Sump Sensor(s). Model: r Fill Sump Sensor(s). Model: r Mechanical Line Leak Detector. Model: r Mechanical Line Leak Detector. Model: r Electronic Line Leak Detector. Model: r Electronic Line Leak Detector. Model: JV_ Tank Overfill/High-Level Sensor.Model: flapper r Tank Overfill/High-Level Sensor.Model: flapper Other(specify equipment type and model in Section E on Pa 2 . Other(specify equipment type and model in Section E on Pae 2). Tank ID: anti freeze-ANTIFREEZE Tank ID: gear oil-GEAR OIL P In-Tank Gauging Probe. Model: mag r7o In-Tank Gauging Probe. Model: mag WO Annular Space or Vault Sensor. Model: 303 r Annular Space or Vault Sensor. Model: 409 WO Piping Sump/Trench Sensor(s). Model: 205 570 Piping Sump/Trench Sensor(s). Model: 205 F Fill Sump Sensor(s). Model: r Fill Sump Sensor(s). Model: r Mechanical Line Leak Detector. Model: r Mechanical Line Leak Detector. Model: r Electronic Line Leak Detector. Model: r Electronic Line Leak Detector. Madel: (✓ Tank Overfill/High-Level Sensor.Model: flapper PO 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 Pae 2). Dispenser Dispenser ID: ID: r Dispenser Containment Sensor(s).Model: r Dispenser Containment Sensor(s).Model: r Shear Valve(s). r Shear Valve(s). r Dispenser Containment Float(s)and Chain(s). r Dispenser Containment Float(s)and Chain(s). Dispenser Dispenser ID: ID: • Dispenser Containment Sensor(s).Model: r Dispenser Containment Sensor(s).Model: • Shear Valve(s). r Shear Valve(s). r Dispenser Containment Float(s)and Chain(s). r Dispenser Containment Float(s)and Chain(s). Dispenser Dispenser ID: ID: r Dispenser Containment Sensor(s).Model: r Dispenser Containment Sensor(s).Model: F Shear Valve(s). r Shear Valve(s). F Dispenser Containment Float(s)and Chain(s). r Dispenser Containment Float(s)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 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,I have also attached a copy of the report; (check all that apply):r System set- up r Alarm history report Technician Name(print): Jarrod Cooke Signature: Certification No.: B35255 License.No.: 743160 Clas'A' Testing Company Name: Tanknology Phone No.: (800)8004633 Testing Company Address: 11000 N.MoPac Expressway Suite 500 Date of Testing/Servicing: 3/8/2013 Monitoring System Certification Page 1 of 4 12/07