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Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.swrcb.ca.gov.) MONITORING SYSTEM CERTIFICATION ... - � _ _ ENVIRONMENTAL t- __ALTH 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: CHRIS ROY 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 soecific eouioment inspected/serviced: Tank ID: motor oil - MOTOR OIL Tank ID: waste oil tank pad - WASTE OIL r— In -Tank Gauging Probe. Model: r In -Tank Gauging Probe. Model: W Annular Space or Vault Sensor. Model: 794390409 W Annular Space or Vault Sensor. Model: 794390407 W Piping Sump / Trench Sensor(s). Model: 794380-205 R Piping Sump / Trench Sensor(s). Model: 794380-208 r Fill Sump Sensor(s). Model: r— Fill Sump Sensor(s). Model: F 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: flapper r Tank Overfill / High -Level Sensor. Model: flapper Other (sDKifv equipment type and model in Section E on Pae 2). F Other (specify equipment type and model in Section E on Pae 2). Tank ID: Tank ID: r In -Tank Gauging Probe. Model: r In -Tank Gauging Probe. Model: F 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: F Fill Sump Sensor(s). Model: r Fill Sump Sensor(s). Model: F 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 ui ment type and model in Section E on Pae 2).. r Other (specify equipment type and model in Section E on Page 2). Dispenser Dispenser ID: ID: F Dispenser Containment Sensor(s). Model: r Dispenser Containment Sensor(s). Model: F 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). r Dispenser Containment Float(s) and Chain(s). r Dispenser Containment Float(s) and Chain(s). Dispenser Dispenser ID: ID: F Dispenser Containment Sensor(s). Model r Dispenser Containment Sensor(s). Model: F 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 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; : (✓ System set- up r✓ Alarm history report Technician Name (print): Steve Willems Certification No.: 836743 _ Signature: License. No.: 743160 Class W Testing Company Name: Tanknology Phone No.: (800) 800-4633 Testing Company Address: 110DO N. MoPac Expressway Suite 500 Date of Testing/Servicing: Monitoring System Certification Page 2 of 4 2/6/2017 12/07