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RECEIVEL Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at: htto://www.waterboards.ca.gov.) 1 q SEP t 2015 MONITORING SYSTEM CERTIFICATION CI L+ For Use By All Jurisdictions Within the State of California AL Authority Cited:Chapter 6.7, Health and Safety Code;Chapter 16, Division 3,Title 23,California Cod 1 tCIV I This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be pMEIW 1W n=6QTIIAC'hIT 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: FOOD&GAS VALERO Bldg.No.: Site Address: 2185 E FREMONT ST City: STOCKTON CA Zip: Facility Contact Person: LAL Contact Phone No.: (-209)547-1700 Make/Model of Monitoring System: VEEDER ROOT TLS-350 Date of Testing/Servicing: 9-22-2014 B. Inventory of Equipment Tested/Certified Check the aperopriate boxes to indicatespecific equipment ins ected/serviced: Tank ID: 870CT Tank ID: DSL N In-Tank Gauging Probe. Model: MAG 1 N In-Tank Gauging Probe. Model: MAG 1 N Annular Space or Vault Sensor. Model: 420 ❑ Annular Space or Vault Sensor. Model: SPLIT N Piping Sump/Trench Sensor(s). Model: 208 N Piping Sump/Trench Sensor(s). Model: 208 N Fill Sump Sensor(s). Model: 208 N Fill Sump Sensor(s). Model: 208 N Mechanical Line Leak Detector. Model: LD-2000 N Mechanical Line Leak Detector. Model: STP-MLD-D ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line 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). ❑ Other(specify equipment type and model in Section E on Page 2). Tank ID: 91 OCT Tank ID: N In-Tank Gauging Probe. Model: MAG 1 ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor, Model: SPLIT ❑ Annular Space or Vault Sensor. Model: N Piping Sump/Trench Sensor(s). Model: 208 ❑ Piping Sump/Trench Sensor(s). Model: N Fill Sump Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: N Mechanical Line Leak Detector. Model: STP-MLD ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line 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). ❑ Other(specify equipment type and model in Section E on Page 2). Dispenser ID: 1-2 Dispenser ID: 5-6 N Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model: 208 N Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 3-4 Dispenser ID: 7-8 N Dispenser Containment Sensor(s). Model: 208 N Dispenser Containment Sensor(s). Model: 208 ® Shear Valve(s). N Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: Sensor(s). Model: ❑ Shear Valve(s). ❑Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑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;(check all that apply): N System set-up N Alarm history report 3 Technician Name(print): David A.Winkler Signature: 1�+ Certification No.: 34975 License No: OTT 08-1739 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 Z STREET GALT,CA 95632 Date of Testing/Servicing: 9-22-2014 Monitoring System Certification Page 1 of 4 2/21/07