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08/22/2012 11:43AN FAX 2093330318 KSM CORP 0003/0008 Appendix VI MONITORING SYSTEM CERTIFICATION For Use Sy All Jurisdictions Within the Stat!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 doau aro testing and servicing of monitoring equipment A separate ratification or moat must be proparod for each monitoring system control panel by the technician who performs the work.R copy or this form must be providied to the tank system ownerlo0orstor,The /operator must submit a copy of this form to the coral agency regulating UST systems within 30 days of test date. A. General Information Facility Narno: KETTLEMEN CHEVRON Bldg,No.; Slt@ Address: 601 KETrLEMEN LN City; LODI Zip: 95240 Facility Contact Person: TONY Contact Phone No.: ( k MakaiModal of Monitoring System: VEEDER ROOT TLS 350 gate of TestinglSenricing; 07.24.12 B. Inventory of Equipment Tested/Certified Check the*EMW bOX06 to indicate 80ftift OQuipment inspected/serviced: Faaso nk ID: 87 Tank ID: 87 In-TankCAuging Probe. Model: MA01 13 In-Tank Gauping Probe, Model: MAG9 Annular Space or vault Sensor, Mesce al: 420 0 Annular Spaor vault Sensor. Modal: 420 Piping Sump r Trench Sensor(s), Mod6 zgs ® Piping Sump/Tronerk Smnsor(s). Model: 208 ❑ Fill Sump SgnsOr(s), Model; ❑ Fill SUMP Sensor(s), Mow: ❑ Mechanical Una Leak Detector. Madel: ❑ M*%Aftir4e1 Lina Leak DoWlat. Model! ® Elocvonio Lina Leak t*octor. Model; PLLD ( E rite Line leak Detector, Model: Pr.,ir) ® Tank Overfill/High-Lewes Sensor, Model: 90% Tank OvertAi 1 High-Lem Sensor, Model. 2M ❑ Other(specify equipment type and model in Seam E on Page 2). ❑ Other(specify equl t type and model In Section E on Page 2), Tank'ID: 91 Tank ID: DIE ® in-Tank Gauging Probe. Model: MAG 1 ® In-Tank Gauging Probe. Madel: MAGI 0 Annular Space or vault Sensor. Modal: 409 1& Annular Space or vault Sensor, Model: 4214 ® Piping Sump/Trench Sensor(s), Model: 208 a Piping Sump/Trench Sensor(s), Model: 20$ ❑ Fid Sump Sonsor(s). Model: ❑ Fill Sump Sensor(&). mow: ❑ Mechanical Line Lank Oatoctor. Model: ❑ MoManical Line Leak Datector. Model: Electronic One leak Oetector. Model: PLL0 Electronic Une leak Detector. Moder; PLLO ® Tank Overfill/High-Laval Seng. Model: 90% ® Tank Overfill 1 High-Level Sensor. Model; 90% ❑ Other(specify equlpntint type and rnoder In Section E on Page 2). ❑ Other(specry equipment type and model In Section E on Pape 2). Dispenses ID: 1-2 Dlspenser ID: 3.4 0 Dispenser Containment s), Model: 20a a Dispenser Containment SenWs). Model: 208 0 Shear Volve(a). 0 Shear Volve(s). ❑ Otspenser Contalinmerd Floats)and Chaln(s), ❑ Dlspenaer Containment Floats)and Chain(s). DispertserID: 5-6 Dispenser ID: 7-8 0 Eh9Qnser Containment Sensor(s), Model; 208 0 Dispenser Containment Sensor(s). Model: 248 ® Shear valve(s), 21 Shear vahre(s), 0 Dispenser Containment Float(s)and Chain(s), ❑ Dispenser Containment Flpat(s)and Chain(s). Disperw r 10: 9-10 Dispener ID: 11-12 ®DISpgnser Containment 0 Dispenser Containment Sensor(%), Modet 208 sensor(S)- Model:208 0 Shear valve(s). 10 Shear Valve(s), ❑ Dispenser COniainmerat Float(3)and Chain(s), ❑Dispenser Containment Float(s)and Chain(s). 9t Sae Facility contains more tanks Or dispensers.copy this form, Include Information for every tank and dispenser at the facility, C.COrtftM*n-t certify that the equipment klonttod in this document was Inspoctotillsormod In accordance with the manufacturers' guidalinse.Aftchod to tris C4rtiflostion is information(e.g.manufacturers'Checklists)necessary to ve ft that this Information Is correct and a Plot Plan showing the layout of nwitod equlpmanL For any equipment capable of generating such reports,I have also attached a copy of the raw,(rbrrk all that apply): ®system sot-up IM Alar history report Technician Name(prim: FELIX RAMIREZ Signature: Certification No.: 3934-UT n N 08 1740.' _ • .... - License O: .._.,...,.�,..,,.--'...--._._ Testing Company Name: AFFOROXTIEST Phone No. 12x9)744.0113 T*Obrg Gempany Aedrowa 416 2'wSTREET GALT CA 45832 _ Dsta w Teshn e i ' : 07-24-12 rip System CenKltcatten Page 1 ofd 2/21/07