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Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.waterboards.ca.gov.) MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of 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. Generallnformation Facility Name: Arco Tracy#83333 Bldg.No.: Site Address: 550 VALPICO ROAD City: Tracy Zip: Facility Contact Person: Dennis A. Contact Phone No.:(209) 836-3327 Make/Model of Monitoring System: TLS 350 Date of Testing/Servicing: 10/8/2012 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates ecific equipment ins ected/serviced: Tank ID: 87 Tank ID: 91 X In-Tank Gauging Probe. Model:_MAG II X In-Tank Gauging Probe. Model:_MAG II X Annular Space or Vault Sensor. Model:_VR-303 ❑ Annular Space or Vault Sensor. Model: X Piping Sump/Trench Sensor(s). Model: VR-208_ X Piping Sump/Trench Sensor(s). Model:–VR-208 X Fill Sump Sensor(s). Model:VR-208 X Fill Sump Sensor(s). Model:–VR-208. ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: X Electronic Line Leak Detector. Model:_8484 X Electronic Line Leak Detector. Model:_8484 ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: X Other(specify equipment t e and model in Section E on Page 2). X Others eci a ui ment type and model in Section E on Pa e 21 Tank ID: DIESEL Tank ID: X In-Tank Gauging Probe. Model: MAG II _ ❑ In-Tank Gauging Probe. Model: X Annular Space or Vault Sensor. Model: VR-303 ❑ Annular Space or Vault Sensor. Model: X Piping Sump/Trench Sensor(s). Model: VR-208 ❑ Piping Sump/Trench Sensor(s). Model: X Fill Sump Sensor(s). Model: VR-208 ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: X Electronic Line Leak Detector. Model: 8484 ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: X Other(specify a ui ment type and model in Section E on Pae 2). ❑ Others eci a ui ment type and model in Section E on Page 2). Dispenser ID:_1/2 Dispenser ID:_3/4 X Dispenser Containment Sensor(s). Model: VR-208 X Dispenser Containment Sensor(s). Model: VR-208 X Shear Valve(s). VR-304 X Shear Valve(s). VR-304 ❑ Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5/6 Dispenser ID: 7/8 X Dispenser Containment Sensor(s). Model:_VR-208 X Dispenser Containment Sensor(s). Model: VR-208 X Shear Valve(s). VR-304 X Shear Valve(s). VR-304 ❑ Dispenser Containment Floats and Chains. ❑ Dispenser Containment Floats and Chain(s). Dispenser ID:_9/10 Dispenser ID: 11/12 X Dispenser Containment Sensor(s). Model: VR-208 X Dispenser Containment Sensor(s). Model:—VR-208 X Shear Valve(s). VR-304 X Shear Valve(s). VR-304 ❑ Dispenser Containment Float and Chains ❑ Dispenser Containment Floats 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): x System set-up ❑Alarm history report Technician Name(print):_LATHAM ZUBILLAGA Signature:'�'a i Certification No.: 5275557 License.No.: Testing Company Name:_Town and Country Contractors Phone No.:(_916_)_636-9500 Testing Company Address:_3181 LUYUNG DR,SUITE A RANCHO CORDOVA CA 95742_ Date of Testing/Servicing:_10_/_8_/_2012 Monitoring System Certification 12/07 1 2/21/07