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1 1111111111 Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at httpJ/www.waterboards.ca.gov.) O C T 2,4' ?0V MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California EALI$�1 Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code �LI1To/f�1 TALHTALHE 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 N. FOOD & GAS VALERO Site Arldracs. 2185 E FREMONT ST Facility Contact Pr?rsnn YUGIRDER Make/Model of Monitoring System: VEEDER ROOT TLS -350 Bldg. No.: City: STOCKTON CA Zip: Contact Phone No.: (-209) 547-1700 B. Inventory of Equipment Tested/Certified Check the aoorooriate boxes to indicate specific eauipment inspected/serviced: Date of Testing/Servicing: 9-24-121 Tank ID: 870CT Signature: T Certification No.: 34975 Tank ID: DSL Testing Company Name: AFFORDA-TEST 21 In -Tank Gauging Probe. Model: MAG 1 In -Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 420 ❑ Annular Space or Vault Sensor. Model: SPLIT ® Piping Sump / Trench Sensor(s). Model: 208 ® Piping Sump /Trench Sensor(s). Model: 208 ® Fill Sump Sensor(s). Model: 208 ® Fill Sump Sensor(s). Model: 208 ® Mechanical Line Leak Detector. Model: LD -2000 ® 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: ❑ In -Tank Gauging Probe. Model: ® In -Tank Gauging Probe. Model: MAG 1 ❑ Annular Space or Vault Sensor. i Model: SPLIT ❑ Annular Space or Vault Sensor Model: ® Piping Sump / Trench Sensor(s). Model: 208 ❑ Piping Sump / Trench Sensor(s). Model: ® Fill Sump Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ® 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 ® Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model: 208 ® 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 ® Dispenser Containment Sensor(s). Model: 208 IRI ni�pa c=r cQ_t_;n. ncnt Ecncc. -, ModcL 202 ® Shear Valve(s). ® 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 al/ that apply): ® System set-up ® Alarm history report Technician Name (print): David A. Winkler Signature: T Certification No.: 34975 License No: OTT 08--11739 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 Testing Company Address: 416 2" STREET GALT, CA 95632 Date of Testing/Servicing: 9-24-12 Monitoring System Certification Page 1 of 4 2/21/07