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4 Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.BWfCb.Ca.g OV.) MONITORING SYSTEM CERTIFICATION i -Lu L, 6 2017 For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, 71t/e 23, California Code of.L HEALTH 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 Facility Contact Person: CHRIS ROY Make/Model of Monitoring System: Veeder Root TLS -300C B. Inventory of Equipment Tested/Certified City: TRACY Zip: 95304 Contact Phone No.: 209-993-7946 Date of Testing/Servicing: 2/6/2017 *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. manufacturerschecklists) necessary to verity 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 appy): Pr System set- up r. Alarm history report Technician Name (print): Steve Willems Certification No.: 836743 Testing Company Name: Tanknology Signature: � License. No.: 743160 Class'A' Phone No.: (800) 8004633 Testing Company Address: 11000 N. MoPac Expressway Suite 500 Date of Testing/Servicing: 2/6/2017 Monitoring System Certification Page 1 of 3 12/07 Tank ID: Soap Tank - OTHER Tank ID: r In -Tank Gauging Probe. Model: r In -Tank Gauging Probe. Model: r Annular Space or Vault Sensor. Model: 794390407 r Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: 794380-205 r Piping Sump / Trench Sensor(s). Model: r 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: {T Tank Overfill / High -Level Sensor. Model: flapper r Tank Overfill / High -Level Sensor. Model: Other(specify equipment a and model r Other(specify equipment a and model in Section E on Pae 2). Tank ID: Tank ID: r In -Tank Gauging Probe. Model: r In -Tank Gauging Probe. Model: r Annular Space or Vault Sensor. Model: r Annular Space or Vault Sensor. Model: r Piping Sump / Trench Sensor(s). Model: r Piping Sump / Trench Sensor(s). Model: r 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: r Tank Overfill / High -Level Sensor. Model: r Tank Overfill / High -Level Sensor. Model: 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 Chaln(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. manufacturerschecklists) necessary to verity 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 appy): Pr System set- up r. Alarm history report Technician Name (print): Steve Willems Certification No.: 836743 Testing Company Name: Tanknology Signature: � License. No.: 743160 Class'A' Phone No.: (800) 8004633 Testing Company Address: 11000 N. MoPac Expressway Suite 500 Date of Testing/Servicing: 2/6/2017 Monitoring System Certification Page 1 of 3 12/07