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Appendix VI MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California U 27 2 0 15, 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 PQarad'jLV _41 v' a eac '— each monitoring system control panel by the technician who performs the work.A copy of this form must be provided to the tanicsystem -- owner/operator.The owner/operator must submit a copy of this form to the local agency regulating LIST systems within 30 days of test date. A. General Information Facility Name: -KETTLEMAN CHEVRON Bldg.No.: Site Address: 601 E. KETTLEMAN city: LODI zip: 95240 Facility Contact Person: TONY Contact Phone No.: ( Make/Model of Monitoring System: VEEDER ROOT TLS-350 Date of Testing/Servicing: 7/22/2015 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates ecic e uipment ins pectad/serviced: Tank ID: 91 Tank Size: Tank ID: 87 - I Tank Size: ED In-Tank Gauging Probe. Model: MAG 1 0 In-Tank Gauging Probe. Model: MAG I • Annular Space or Vault Sensor. Model: 407 [D Annular Space or Vault Sensor. Model: 420 • Piping Sump/Trench Sensor(s). Model: 208 0 Piping Sump/Trench Sensor(s). Model: 208 El Fill Sump Sensor(s). Model: 0 Fill Sump Sensor(s). Model: E] Mechanical Line Leak Detector. Model: E] Mechanical Line Leak Detector. Model: [0 Electronic Line Leak Detector. Model: P L L D 0 Electronic Line Leak Detector. Model: PLLD El Tank Overfill/High-Level Sensor. Model: El Tank Overfill/High-Level Sensor. Model: [I Other(specify equipment type and model in Section E on Page 2). El Other(specify equipment type and model in Section E on Page 2). Tank ID: DIE Tank Size: Tank ID: 87 -2 Tank Size: Z In-Tank Gauging Probe. Model: MAG 1 0 In-Tank Gauging Probe. Model: MAG I ID Annular Space or Vault Sensor. Model: 420 Z Annular Space or Vault Sensor. Model: 420 0 Piping Sump/Trench Sensor(s). Model: 208 ED Piping Sump/Trench Sensor(s). Model: 208 El Fill Sump Sensor(s). Model: El Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: D Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: P L L D Electronic Line Leak Detector. Model: PLLD El Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: [I Other(specify equipment type and model in Section E on Page 2). El Other(specify equipment type and model in Section E on Page 2). Dispenser ID: I / 2 Dispenser ID: . 3 / 4 • Dispenser Containment Sensor(s). Model: 208 Z Dispenser Containment Sensor(s). Model: 208 • ShearValve(s). 0 ShearValve(s). C] 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 0 Dispenser Containment Sensor(s). Model: 208 • ShearValve(s). 0 ShearValve(s). [] Dispenser Containment Float(s)and Chain(s). [] Dispenser Containment Float(s)and Chain(s). Dispenser ID: 9 / 10 Dispenser ID: 11 / 12 0 Dispenser Containment • Dispenser Containment Sensor(s). Model: 208 Sensor(s). Model: 208 • ShearValve(s). 10 Shear Valve(s). El Dispenser Containment Float(s)and Chain(s). El 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): 0 System set-up IZ Alarm history report Technician Name(print): ZANE NIMMO Signature: Certification No.: A28446 License No: 04-1676 Testing Company Name: AFFORDA-TEST Phone No. (2 9)744-0113 Testing Company Address: 416 2 n,STREET GALT,CA 95632 Date of Testing/Servicing: 7/22/2015 Monitoring System Certification Page 1 of 2/21/07