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0 Appendix Vi (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at htff.//-w-w-w-.-w-a-te-r-b--o-ar-ds.-ca.qov.) MONITORING SYSTEM CERTIFICATION 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, 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 LIST systems within 30 days of test date. A. General Information Facility Name: TRACY TRUCK&AUTO Bldg.No.: Site Address:— 3940 N.TRACY BLVD. City: TRACY — Zip: Facility Contact Person; DEBBIE AND CJ Contact Phone No.:( 209 632-600 Make/Model of Monitoring System: TILS EMC 350 Date of Testing/Servicing: 04 / 16 2014 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates iflc eguippent trial ected/serviced., Tank to: TANK I REG UNIL LIST Tank ID: TANK 4 DIESEL EAST UST • In-Tank Gauging Probe. Model: MAG 1 0 In-Tank Gauging Probe. Model: MAG I • Annular Space or Vault Sensor. Model: 408 0 Annular Space or Vault Sensor. Model: 408 • Piping Sump/Trench Sensor(s). Model: 208 ED Piping Sump/Trench Sensor(s). Model: 208 0 Fill Sump Sensor(s). Model: '-'j Fill Sump Sensor(s). Model: I@ Mechanical Line Leak Detector. Model: LD-2000 0 Mechanical Line Leak Detector. Model: LP-M 0 Electronic Line Leak Detector. Model: ,I Electronic Line Leak Detector. Model: 0 Tank Overfill/High-Level Sensor. Model: DROP TUBE VALVE 0 Tank Overfill/High-Level Sensor. Model: DROP TUBE VALVE 0 Other(sp2Effy equ!eent to and model in Section E on Page 2). E 2!t2LLsp2d If 2quipTent b22 and model in Section E on PaLe 2). Tank to: TANK 2 SUPER UST Tank ID: TANK 6 AST EAST 0 In-Tank Gauging Probe. Model: MAG 1 0 In-Tank Gauging Probe. Model: MM I CR Annular Space or Vault Sensor. Model: 408 0 Annular Space or Vault Sensor. Model: 40 I@ Piping Sump/Trench Sensor(s). Model: 208 19 Piping Sump/Trench Sensor(s). Model: 208 U Fill Sump Sensor(s). Model: L Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: LD-2000 Mechanical Line Leak Detector. Model: :3 Electronic Line Leak Detector. Model: 7 Electronic Line Leak Detector. Model: 0 Tank Overfill/High-Level Sensor, Model: DROP TUBE VALVE u Tank Overfill/High-Level Sensor. Model: D Others 2quipMent and model in Section E on Pa2e 21. E Other�specj!y Nuiement D22 and model in Section E on Page 2). Tank ID: TANK 3 DIESEL WEST UST Tank to: TANK 6 6§T MST • In-Tank Gauging Probe. Model: MAG 1 0 In-Tank Gauging Probe. Model: MAG I • Annular Space or Vault Sensor. Model: 408 0 Annular Space or Vault Sensor. Model: 400 • Piping Sump/Trench Sensor(s). Model: 208 0 Piping Sump/Trench Sensor(s). Model: 208 D Fill Sump Sensor(s). Model: - Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: LD-2000 0 Mechanical Line Leak Detector. Model: D Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: C@ Tank Overfill/High-Level Sensor. Model: DROP TUBE VALVE Tank Overfill!High-Level Sensor. Model: 11 Others equipTent and model in Section E on Page 2). C Others !9uIpnent!ype and model In Section E22 Pa a 2). Dispenser to: Dispenser ID: F1 Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: 11 Shear Valve(s). o Shear Vatve(s)' U -Dispenser Containment Floats and Chain(s). ,--i Dispenser Containment Float(s)and Chain(s). Dispenser to: I THRU 8 Dispenser ID: 11THRU18 F1 Dispenser Containment Sensor(s). Model: �_- Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). N Shear Valve(s). N Dispenser Containment Floats2 and Chains 0 Dispenser Containment Floats)and.Chains j_ *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 gen ting such reports,I have also attached a copy of the report(check all that apply): 0 System set-up 0 Alarm history report '. Technician Name(print): GREG KAISER Signature: Certification No.: A26983 License.No.: 859&47 I Testing Company Name: KAISER COMMERCIAL PETROLEUM Phone No.:( 209 ) $87-2639 Testing Company Address: PO BOX 1058,LINDEN,CA 96236 Date of Testing/Servicing: 21 / 16 2014 Monitoring System Certification Page I of 4 12107 2/21/07