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A. . A a. From: Franzen -Hill Inc. To: 12094683433 0 Page: 416 Date: 4/18/2011 9:57:58 AM 0 Appendix Vt (Copies of Monitoring System Certification form and UST Monitoring Plot Pian available at htt :Iiwww.waterboards.ca. ov,) For Use By All Jurisdictions Within the State of Callfomla 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 servloing 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 ownerloperator. The ownerloperator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. General Information Facility Name: Lathrop Shell Bldg. No.: Site Address: 16500 $Hartan 01ty: Lgthrop Zip: Facility Contact Person: Nick Contact Phone No.: s( 209 3 403-38% MakalModet of Monitoring System: SLS 350 Date of TestinglSenkcing: 021Q7l 01 Inventory of Equipment TestedlCertified Cheekthearip priate boxes to f dtcate specifirgeagiviment InsnectedtseMiced, Tank 10: # - 87 Regular Tank I013 - Diesel E In -Tank Gauging Probe. Model: 109 E In-TankGauging Probe. Model: 102 E Annular Space or Vault Sensor. Model: 02 E Annular Space or Vault Sensor. Model: E Piping Sump I Trench Sensor(s). Model: 208 E Piping Sump I Trench Sensor(s). Model: go E Fill Sump Sensor(s). Model: E Fill Sump Sensor(s). Model: 208 E Mechanical Line Leak Detector. Model: VMI E Mechanical Line Leak Detector. Model: FE Petro E Electronic Line Leak Detector. Model: _ E Electronic Line Leak Detector. Model: E Tank Overfill I High -Level Sensor. Model:.flap E Tank Overfill I High -Levet Sensor. Model: E Other (specify equipment type and model In Section E an Page 2). E Other (specify equipment type and model In Section E on Page 2). Tank ID: *2 -91 Premium Tank ID: E In -Tank Gauging Probe. Model: 109 E In -Tank Gauging Probe. Model: E Annular Space or Vault Sensor. Model: E Annular Space or Vault Sensor. Model: E Piping Sump I Trench Sensor(s). Model: 20B E Piping Sump I Trench Sensor(s). Model - I, Fill Sump Sensor(s). Model: E Fill Sump Sensor(s). Model: E Mechanical Line Leak Detector. Model: VMI E Mechanical Line Leak Detector. Model: JE Electronic Line Leak Detector. Model: E Electronic Line Leak Detector. Model: E Tank Overfill I High -Level Sensor. Model: flap E Tank Overfill I High -Level Sensor. Model: E Other (specify equipment type and model in Section E on Page 2). E Other (speciry equipment type and model In Section E on Page 2). Dispenser ID: Dispenser ID: 7 - B Dispenser Containment Sansor(s). Model: Dispenser Containment Sensor(s). Model: Shear Vatve(s). Shear Vatve(s). X Dispenser Containment Float(s) and Cha€n(s), X Dispenser Containment Ftoat(s) and Chain(s). Dispenser ID: 3 - 4 Dispenser 10: Dispenser Containment Sensor(s). Model: E Dispenser Containment Sensor(s). Model: Shear Valve(s). E Shear Valve(s). X Dispenser Containment Floats and Chains . E Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5 - 6 Dispenser ID: Dispenser Containment Sensor(s). Model: E Dispenser Containment Sensor(s). Model: Shear Valve(s). E Shear Valve(s). X Dispenser Containment Float(s) and Chain(s E 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 Piot 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): E Sy`st (sett-u� ! . 6At rm history report Technician Name (print): Stephen Zwahlen Signature: W ' U�< s Certification No.: _4341047029 License. No.: Testing Company Name: Franzg_n Hill Phone No.:(______� Testing Company Address 11100 N J Street Tulare, CA 93274 Date of TestingtServicing: .21712011 Monitoring System Certification Page 1 of 4 This fax was sent with GFI FAXmaker fax server. For more information, visit: http://www.gfi.com 12107