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Appendix VI pi, E D (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http7/www.swrCb.Ca.goV.J= MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California 2 8 2017 Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations ENWi . ?LTH This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitorrig 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 Site Address: 1535 E PESCADERO AVE Facility Contact Person: CHRIS ROY Bldg. No.: City: TRACY Zip: 95304 Contact Phone No.: 209-993-7946 Make/Model of Monitoring System: Veeder Root TLS -350 Date of Testing/Servicing: 2/6/2017 B. Inventory of Equipment Tested/Certified Check the aoorooriate boxes to indicate specific eauioment inspected/serviced: Tank ID: waste oil near rack - WASTE OIL Tank ID: waste oil near gate - WASTE OIL r In -Tank Gauging Probe. Model: r In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 794380-303 r Annular Space or Vault Sensor. Model:794380-303 Pr Piping Sump / Trench Sensor(s). Model: 794380-208 N. Piping Sump / Trench Sensor(s). Model: 794380-205 r Fill Sump Sensor(s). Model: r Fill Sump Sensor(s). Model: rMechanical Line Leak Detector. Model: r Mechanical Line Leak Detector. Model: r Electronic Line Leak Detector. Model r Electronic Line Leak Detector. Model: jJ Tank Overfill / High -Level Sensor. Model: flapper Pr, Tank Overfill / High -Level Sensor. Model: flapper Other(specify equipment a and model in Section E on Pae 2). r Other(specify equipment a and model In Section E on Pae 2). Tank ID: anti freeze - ANTIFREEZE Tank ID: gear oil - GEAR OIL r In -Tank Gauging Probe. Model: r In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 794380-303 R Annular Space or Vault Sensor. Model: 794390-407 Pr Piping Sump / Trench Sensor(s). Model: 794380-205 F Piping Sump / Trench Sensor(s). Model: 794380-205 r Fill Sump Sensor(s). Model: r Fill Sump Sensor(s). Model: rMechanical Line Leak Detector. Model: r Mechanical Line Leak Detector. Model: r Electronic Line Leak Detector. Model: r Electronic Line Leak Detector. Model: r Tank Overfill / High -Level Sensor. Model: flapper r Tank Overfill / High -Level Sensor. Model: flapper Other(specify equipment a and model in Section E on Pae 2). Other(specify equipment a 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: r Dispenser Containment Sensor(s). Model: r Dispenser Containment Sensor(s). Model: r Shear Valve(s). r Shear Valve(s). 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: r Shear Valve(s). r Shear Valve(s). r 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 forth. 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): P System set- up Pr Alarm history report Technician Name (print): Steve Willems Certification No.: B36743 Signature: � License. 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: 2/6/2017 Monitoring System Certification Page 1 of 4 12/07