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In C Appendix VI OR EC F_ -WED MONITORING SYSTEM CERTIFICATI VI U'V'V'Lly i HEALTH For Use By All Jurisdictions Within the State of CaliforniaPERMIT/SERVICES 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. General Information Facility Name: KETTLEMEN CHEVRON Bldg. No.: Site Address: 601 KETTLEMEN LN City: LODI Zip: Facility Contact Person: TONY Contact Phone No.: ( ) Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 07.26-10 B. Inventory of Equipment Tested/Certified rhark tha annrnnriate hnxPs to indicate snecific enuinment Insnected/serviced: Tank ID: 87 Tank ID: 87 ® in -Tank Gauging Probe. Model: MAG 1 ® In -Tank Gauging Probe. Model: MAG 1 I@ Annular Space or Vault Sensor. Model: 420 ® Annular Space or Vault Sensor. Model: 420 ® Piping Sump / Trench Sensor(s). Model: 208 ® Piping Sump / Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: PLLD ® Electronic Line Leak Detector. Model: PLLD ® Tank Overfill / High -Level Sensor. Model: 90% ® Tank Overfill / High -Level Sensor. Model: 90% ❑ 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 DIE ® In -Tank Gauging Probe. Model: MAG 1 7Tank Gauging Probe. Model: MAG1 ® Annular Space or Vault Sensor. Model: 409 Space or Vault Sensor. Model: 420 ® Piping Sump/ Trench Sensor(s). Model: 208 ® Piping Sump / Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: PLLD ® Electronic Line Leak Detector. Model: PLLD ® Tank Overfill / High -Level Sensor. Model: 90% ® Tank Overfill / High -Level Sensor. Model: 90% ❑ 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: 3-4 ® 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: 5-6 Dispenser ID: 7-8 ® 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: 9-10 DispenserlD: 11-12 ® Dispenser Containment ® Dispenser Containment Sensor(s). Model: 208 Sensor(s). Model: 208 El 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 Pian showing the layout of monitoring equipment. For any equipment capable of generating such reports, 1 have also attached a copy of the report; (check all that apply): ® System set-up ® Alarm history report Technician Name (print): FE:IX RAMIREZ Signature: aIte- ". Certification No.: 5273934 -UT License No: 08-1740 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 Testing Company Address: 416 2" STREET GALT, CA 95632 Date of Testing/Servicing: 07-26-10 _ Monitoring System Certification Page 1 of 4 2/21/07