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a 0 RECEIVED Appendix VI OCT MONITORING SYSTEM CERTIFICATION 1 For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, Califor ip A HEALTH This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must b =V each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the n rilj 6 M ENT 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 Facility Name: TRACY VALERO Bldg. No.: Site Address: 2375 TRACY BLVD City: TRACY Zip: Facility Contact Person: HAKAM Contact Phone No.: (209) 835-5358 Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 09-29-14 B. Inventory of Equipment Tested/Certified Check the aEEroEriate boxes to indicates ecific a ui ment inspected/serviced: Tank ID: 87 Tank ID: 89 ® In -Tank Gauging Probe. Model: MAG ® In -Tank Gauging Probe. Model: MAG ® Annular Space or Vault Sensor. Model: 407 ® Annular Space or Vault Sensor. Model: 407 ® 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: LD 2000 ® Mechanical Line Leak Detector. Model: LD 2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ID Tank Overfill / High -Level Sensor. Model: FLAPPER ® Tank Overfill / High -Level Sensor. Model: FLAPPER ❑ 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 Tank ID: WASTE OIL ® In -Tank Gauging Probe. Model: MAG ❑ In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 407 ® Annular Space or Vault Sensor. Model: 407 ® Piping Sump / Trench Sensor(s). Model: 208 ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: LD 2000 ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: FLAPPER ❑ 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). Dispenser ID: 1-2 Dispenser ID: 3-4 ® Dispenser Containment Sensor(s). Model: 332 ® Dispenser Containment Sensor(s). Model: 332 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 3-4 Dispenser ID: 5-6 ® Dispenser Containment Sensor(s). Model: 332 ® Dispenser Containment Sensor(s). Model: 332 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: Sensor(s). Model: ❑ 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 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 ® Alarm history report Technician Name (print): FELIX RAMIREZ Signature: -`"1► 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: 09-29-14 Monitoring System Certification Page 1 of 4 2/21/07