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11 4p RECT AUG � 5 ?11;15 Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.waterboards.ca.gov.) MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of Califomia Authority Cited: Chapter 5.7, 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 Stockton Bldg. No.: Site Address: 7373 West Lane City: Stockton Zip: 95210 Facility Contact Person: Darryl Gardner Contact Phone No.: () Make/Model of Monitoring System: Veeder Root - TLS350 Date of Testing/Servicing: 7/7/2015 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicates ecificequipment Insi acted/serviced: Tank ID: DSL Tank ID: d in -Tank Gauging Probe. Model: MAG In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: Annular Space or Vautt Sensor. Model: d Piping Sump / Trench Sensor(s). Model: 794380-208 Piping Sump / Trench Sensor(s). Model: Fill Sump Sensor(s). Model: FII Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: V Tank Overfill / High -Level Sensor. Model: Annunciator Tank Overfill / High -Level Sensor. Model: El Others ci egu!E=ent tyE2 and model in Section E on Page 2). Other (specify a ui ment and model in Section E on Pa2e 2 . TanklD: TanklD: In -Tank Gauging Probe. Model: In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: Annular Space or Vauft Sensor. Model: Piping Sump/ Trench Sensor(s). Model: Piping Sump / Trench Sensor(s). Model: Fill Sump Sensor(s). Model: FlII Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: Tank Overfill / High -Level Sensor. Model: Other (speclf a ui ent tvpe and model in Section E on Plue 2L Other sEecU a ui ent a and model in Section E on Pae 2). Dispenser ID: 5penserID: Dispenser Containment Sensor(s). Model: Shear Valve(s). Dispenser Containment Sensor(s). Model: Shear Valve(s). Dis nser Containment Floats and Chains . Dis eraser Containment Floats and Chains . Dispenser ID: Dispenser 10: Dispenser Containment Sensor(s). Model: Shear Valve(s). Dispenser Containment Sensogs). Model: Shear Valve(s). Dis nser Containment Float(s) and Chain(s). Dis enser Containment Float s) and Chain(s). DispenserlD: Dispenser ID: Dispenser Containment Sensogs). Model: Shear Valve(s). Dispenser Containment Sensor(s). Model: Shear Valve(s). H Dis nser Containment Float(s) and Chain (s Dispenser Containment Float(s and Chain(s). . ft 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 inspec tedrserviced 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 Piot Plan showing the layout of momtonng equipment. For any equipment capable of generating such reports, I have also attached a copy of the repos; (checkoff that apply} System set-up 0 Alarm history report Technician Name (print): David Walker Signature: s Certification No.: A32030 License.•-f`io.: 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: 7/7/2015 Monitoring System Certification Page 1 of 4 12107