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Appendix VI 0 RECEIVEE (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.waterboards.ca.ciov.) 015 MONITORING SYSTEM TIFIC TIO For Use By Al! Jurisdictfons Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, Calif pia a 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.: (j Make/Model of Monitoring System: Veeder Root -TLS 250 1 Date of Testing/Servicing: 1/7/2015 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicates ecific a ui ment Im ected/serviced: Tank ID: DSL Tank ID: d In -Tank Gauging Probe. Model: in -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: - Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: 794 0-205 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: Flapper Tank Overfill / High -Level Sensor. Model: Other (specil a ui ent t and model in Section E on Pae 21. Other (specly (spec'equipment t and model in Section E on Pae 2). TanklD: TankiD: In -Tank Gauging Probe. Model: in -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: 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: Tank Overfill / High -Level Sensor. Model: -2). Tank Overfill / High -Level Sensor. Model: Others ci equipment t and model in Section E on Taqe Other eclfy a ui ment and model in Section E on Pae 2 . DispenserlD: enserlD: Dispenser Containment Sensor(s). Model: Shear Valve(s). Dispenser Containment Senors). Model: Shear Valve(s). Dis nser Containment Float�sj and Chains . Dispenser Containment Floats and Chains . DispenserlD: Dispenser ID: Dispenser Containment Senors). Model: Shear Valve(s). Dispenser Containment Sensor(s). Model: Shear Valve(s). Dis nser Containment Floats and Chains . Dis enser Containment Floats and Chains . Dispenser ID: Dispenser ID: Dispenser Containment Sensor(s). Model: Shear Valve(s). Ll Dispenser Containment Senors). Model: Shear Valve(s). D!sE2nser Containment Float�sj and Chains Dis enser Containment Floats 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 inspectedfserviced 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 momtonjql equipment. For any equipment capable of generating such reports, I have also attached a copy of the report; (checkalf that apply):System set-up ❑d Alarm history report Technician Name (print): David Walker Signature:�---- Certification No.: A32030 License. No.: 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: 1/7/2015 Monitoring System Certification Page 1 of 4 12107