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w TU Appendix VI JUL MONITORING SYSTEM CERTIFICATION SAN J0A0U1N COUNTY For Use By All Jurisdictions Within the State of California EyVIRONMENTAL Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Co LTN DEPARTMENT 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. General Information FacilityKETTLEMAN CHEVRON Bidg. No.: Namo• Site 601 E KETTLEMAN LANE City: LODI Zip: Addrr+.c¢• Facility Contact TONY Contact Phone No.: Parann Date of Testing/Servicing: 7/9/2009 Make/Model of Monitoring System: VEEDER ROOT TLS -350 Inventory of Equipment Tested/Certified _At-......riwea• Check the aEgroEriate boxes to indicates ecmc a ui maIu 111*Ci 16ul7 v.v. v. Tank ID: 87 EAST Tank ID: 91 OCT ® 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: 409 ® 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: ❑ 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: ❑ 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: 87 WEST Tank ID: DSL ® 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: 420 ® 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: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: PLLD ® Electronic Line Leak Detector. Model: PLLD ❑ 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). -2 Dispe:,r: Dispenser ID: 7-8 ® Disnment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model: 208 ® Sh® Shear Valve(s).❑ Disnment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 3-4 Dispenser ID: 9-10 ® 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: 6-6 Dispenser ID: 11-12 ® Dispenser Containment ® Dispenser Containment Sensor(s). Model: 208 Sensor(s). Model: 208 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). a #-L, ar.rt Acnranar r nt thr facility. `If the facility contains more tanks or dispensers, copy im5 ldnn. include a ivi mauvn .v. eve. y 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): ® System set-up tO Alarm history report Technician Name (print): David A. Winkler Signature: (ice,) Certification No.: 34975 License No: ; OTT 08-1739 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 Testing Company Address: 416 2" STREET GALT, CA 95632 Date of Testing/Servicing: 7-9-09 Monitoring System Certification Page 1 of 4 2/21/07