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Appendix VI �, : r C Va (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at hitp://W W W svvrcb.Ca gov ) MONITORING SYSTEM CERTIFICATION v u ��ii ENVIRONMENTAL HEALTH 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 FacilityName: YRC 813 Site Address: 1535 E PESCADERO AVE Facility Contact Person: CHRIS ROY Bldg. No.: City: TRACY zip: 95304 Contact Phone No.: 209993-7946 Make/Model of Monitoring System: Veeder Root TLS -300C Date of Testing/Servicing: 2/6/2017 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: Soap Tank - OTHER Tank ID: f— In -Tank Gauging Probe. Model: r In -Tank Gauging Probe. Model: WO Annular Space or Vault Sensor. Model: 794390407 r Annular Space or Vault Sensor. Model: P_ Piping Sump / Trench Sensor(s). Model: 794380-205 r Piping Sump / Trench Sensor(s). Model: 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: r Tank Overfill / High -Level Sensor. Model: Flapper r Tank Overfill / High -Level Sensor. Model: Other (specify ui ment type and model in Section E on Pae 2). r Other (specify ui ment type and model in Section E on Page 2). Tank ID: Tank ID: F In -Tank Gauging Probe. Model: r In -Tank Gauging Probe. Model: F Annular Space or Vault Sensor. Model: F Annular Space or Vault Sensor. Model: F Piping Sump / Trench Sensor(s). Model: F Piping Sump / Trench Sensor(s). Model: 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: r Tank Overfill / High -Level Sensor. Model: r Other (specify ui ment type and model in Section E on Pae 2)T.— r Other (specify equipment type and model in Section E on Pae 2). Dispenser Dispenser ID: ID: F 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: F Shear Valve(s). r Shear Valve(s). I- 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 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; W System set- up W Alarm history report Technician Name (print): Steve Willems Certification No.: 835743 Testing Company Name: Tanknology Signature: License. No.: 743160Class'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