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I `'%W Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.waterboards.ca.ciov.) MONITORINGSYSTEM CERTIFICATION For Use By Alt Jurisdictions Within the State of California 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. A. General Information Facility Name: Kaiser Manteca Bldg. No.: Site Address: 1777 W. Yosemite Avenue City: Manteca Zip: 95336 Facility Contact Person: Sam Corbin , Contact Phone No.: () Make/Model of Monitoring System: Veeder Root - TLS 350 Date of Testing/Servicing: 7/15/2015 B. Inventory of Equipment Tested/Certified Check theappropriate boxes to Indicatespecific ul meet ins ectediserviced: Tank ID: T1 Diesel Tank AST Tank ID: T2 UST Diesel V In -Tank Gauging Probe. Model: IMAG Plus d In -Tank Gauging Probe. MAU Plus Model: Annular Space or Vault Sensor. Model: d Annular Space or Vault Sensor. Model: -303 Piping Sump/ Trench Sensor(s). Model: d Piping Sump / Trench Sensor(s). Model: ' 208 Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Fill Sump Sensor(s). Mechanical Line Leak Detector. Model: Model: Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: MAG Plus Electronic Line Leak Detector. V_ Tank Overfill / High -Level Sensor. Model: Model: MAG Plus Others ci a ui ent and model in Section E on E2L9 U Other (speca (spec'equipMent to and model in Section E on Page 2 . Tank ID: Tank ID: In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: In -Tank Gauging Probe. Annular Space or Vault Sensor. Model: Model: Piping Sump / Trench Sensor(s). Model: Fill Sump Sensor(s). Model: Piping Sump / Trench Sensor(s). Fill Sump Sensor(s). Model: Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: OtherL&2cie9ulEMent type and model in Section E on Pa e 2). r Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: Other ecU equigMent and model in Section E on Page 21 Dispenser ID: Dispenser Containment Sensor(s). Model: Dispenser113: Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). Dispenser Containment Floats and Chains . Dis enser Containment Floats and Chains . DispenserlD: Dispenser Containment Sensor(s). Model: Shear Valve(s). D1."nserID: Dispenser Containment Sensor(s). Model: Shear Valve(s). Dispenser Containment Fioat(s and Chain(s). Dis enser Containment Float(s) and Chafn(s). DispenserlD: Dispenser Containment Sensor(s). Model: Dispenser ID: Dispenser Containment 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 verity 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; (checkaff that apply} d6 System set-up O Alarm history report (} Technician Name (print): David Walker Signature: ____ D \ _N a x,& - Certification No.: A32030 License. -'o.: 808313 Testing Company Name: Belshire Environmental Services, Inc. Phone No.: 9( 49 ) 460-5200 Testing Company Address: 25971 Towne Centre Dr., Foothill Ranch, CA 92610 Date of Testing/Servicing: 7/15/2015 Monitoring System Certification Page 1 of 4 12107