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• • Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://A,%,v%v.witerboard.s.ca.gov.) MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the Slate ofCalifornfa Authority Cited. Chapter 6.7,Health and Safety Code;Chapter 16,Division 3,Title 23,California Code ofRegu/ations This form must be used to document testing and servicing of monitoring equy3ment.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: JB Hunt Facility ID: 01 Site Address: 2726 Loomis Rd. City: Stockton Zip: 95205 Facility Contact Person: Ron Weaver Contact Phone No.: 916-439-3477 Make/Model of Monitoring System: Veeder Root TLS-350 Date of Testing(Servicing: 2015-11-25 B. Inventory ofliquipment Tested/Certi fled REG Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: T1:Diesel _ 'rank ID ® In-Tank Gauging Probe. Model: 846390-109 ❑In-Tank Gauging Probe. DELIvadf X❑Annular Space or Vault Sensor. Model: 794390-420 ❑Annular Space or Vault ' or. Model: ❑Piping Sump/Trench Sensor(s). Model: ❑Piping Sump/Trench Sd�r Fill Sump Sensor(s). Model; ❑Fill Sump Sensor(s). QT41r�r•- QMechanical Line Leak Detector. Model: LD2000 '❑Mechanical Line Leak Detector Model: ❑ Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ©Tank Overfill/High-Level Sensor. Model: 790091-001 ,❑Tank Overfill/High-Level Sensor, Model: 0 Other(specify equipment type and model in Section E on Page 2). ❑Other(s ecil'y equipment type and model in Section E on Pae 2). Tank ID: Tank ID ❑In-Tank Gauging Probe. Model ❑in.rank Gauging Probe. Model: ❑Annular Space or Vault Sensor. Model ❑Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑Piping Sump/Trench Smsor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑Fill Sump Scnsor(s). Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑Electronic L ine Leak Detector. Model: ❑Tank Overfill/High-Level Sensor. Model ❑Tank Overfill/High-Level Sensor. Model: ❑Other(specify equipment type and model in Section E on Page 2). 1❑Other(specify equipment type and model in Section E on Page 2). Dispenser ID: Diesel 1/2 Dispenser ID: Sat.East © Dispenser Containment Sensor(s). Model: 794380-208 ❑X Dispenser Containment Sensor(s). Model: 794380-208 Shear Valve(s). Q Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Cbain(s). Dispenser iD: Sat.West Dispenser iD• _ Y Dispenser Containment Sensor(s). Model: 794380-208 ❑Dispenser Containment Sensor(s). Model: 0 Shear Valve(,). ❑Shear Valvc(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). •if the facility ocrtains more tanks ordi,pensers,copy this form.Include infermatien formery 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 tothis Certification is information(cg.manufacturers'checklists)necessary to verify that this information is correctand a Plot Plan showing the layout of monitoring equipment.For any equipment capable of generatingsuch reports,I have also attached a copy of the report;(check alithatapply) : ❑X System set-up Q Alarm history report Technician Name(print): Victor Guerrero '?Iw" ��t Signature: tt// Certification No.: 836532 License. No.: 588098 Testing Company Name: TAiT ENVIRONMENTAL SERVICES Phone No.: 714560-8222 Testing Company Address: 2131sotm DuPoNTnRrvKANJMKCA92W6 Date ofTesting/Servicing: 2015-11-25