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Jan 0815 07:01 a Radius Petroleu Services 209-474-9171 p.1 Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http:/,'www.waterboards.ca-qov.) MONITORING SYSTEM CERTIFICATION For Use By All Jurlsdictions 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 Sheriffs Fuel Site Facility Name: Bldg-No. Site Address: 7d00 Micheal Cantis City: French Camp zip, 95231 Facility Contact Person: Dan McCann Contact Phone No.: 2( O9 ) 468-4645 MakeiModel of Monitoring System: Veeder Root TLS 350 Date of Test#rg/Servicing:01;06;2015 B. Inventory of Equipment Tested/Certified Chock the appropriate boxes to indicate s cific ui meot in cted/serviced: Tank ID: Tank(l) Gas Tank ID: X In-Tank Gauging Probe. Model: VR rotas plus Probe C In-Tank Gauging Probe. Model: x Annuiar Space or Vault Sensor. Model: VR 409 E Annular Space or Vault Sensor. Model: B Piping Sum i Trench Sensor(s). Model: VR 208 C Piping Sump!Trench Sensor(s). Model: Fill Sump Sensor(s). Model: C Fill Sump Sensor(s). Model: Mechanical Line Leafs Detector. Model: C Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: C Electronic Line Leak Detector. Model: x Tank Overtill 1 High-Level Sensor. Model:opw valve&-nag plus probe L Tank Overfill,High-Level Sensor. Model: # - Other s eef a ui ment t=and model in Section E on Pae 2). C Other(specify equi2ment type and model in Section E an Pae 2. Tank ID: Tank(2) Diesel Tank ID: ix 1n-Tank Gauging Probe. Model: Vn Mag probe is In-Tank Gauging Probe. Madel: X Annular Space or Vault Sensor. Model: VR 40e C Annular Space or Vault Sensor. Model: X Piping Sump i Trench Sensor(s). Model: VR 208 E Piping Sump!Trench Sensor(s), Model: ❑ F#II Sump Sersorfs). Model. [ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: C Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: C Electronic Line Leak Detector. Model: g Tank Overfill?High-Level Sensor. Model: oaw valve&may probe C Tank Overfill i High-Level Sensor, Model: Other sgeciN equipment t e and model in Section E on P e g). ❑ Other(se!c!N 2quipment and model in Section E qD_pa lq9e 21. Dispenser ID: Pump 112 Dispenser ID: x Dispenser Containment Sensor(s). Model: VR 208 ❑ Dispenser Containment Sensor(s). Model: Z Shear Valve(s). ❑ Shear Valve(s). Dispenser Containment Floats and Chain(s). C Dispenser Containment Floads and Chain(s). Dispenser 1D: ?ump314 Dispenser ID: Dispenser Containment Sensor(s). Model: '/R 2D8 ❑ Dispenser Containment Sonsor(s). Model: Shear Valve(s). C Shear Valve(s). Dispenser Containment Floai s and Chain(s). C Dispenser Containment Float's and Chains. Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chains ❑ Dispenser Containment Floats and Chains. "If the facility contains more tarks.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/serAced In accordance with the manufacturers' guidelines. Attached to this certification is information(e.g. manufacturers'checklists)necessary to verdy 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 appfy): �2 System set-up im Alarm history report Technician Name(print): Eric naagaard Signature: ICC tech 5250200 exp(7211212015 774802 Certification No.: VR ID A279e5 exp 111t71a01e License.No.: Testing Company Name: Bayley Enterprises,Inc Phone No.: 20( 9 ) 3674WO Testing Company Address: 2370 Maggo olr&A6 4 Lo(€,CA 95240 Date of Testing/Servicing:0S 1 M i 2015 Monitoring System Certification Page t of 4 12107 1 2121/07