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HECEIVED JUC 3 12015 Appendix V1 (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at httNO T WrIESEALTH 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: 96304 Facility Contact Person: DEBBIE AND CJ Contact Phone No.:( 209 53245006 Make/Model of Monitoring System: TLS EMC 350 Date of Testing/Servicing:_912_9 2015 B. Inventory of Equipment Tested/Certified Check the amroerlate boxes to indicate sp!cific aqui meat ins ectediserviced: Tank ID: TANK I REG UNIL UST Tank ID: TANK 4 DIESEL EAST UST Model: MAG 1 [9 In-Tank Gauging Probe. Model: MAG 1 0 In-Tank Gauging Probe. N to Model: 420 Annular Space or Vault Sensor. Model: 420 19 Annular Space or Vault Sensor. N N Piping Model: 208 Piping Sump/Trench Sensor(s). Model: 208 19 Piping Sump I Trench Sensor(s). Fill S - Fill Sump Sensor(s). Model: D Fill Sump Sensor(s). Model: 0 Mechanical hanical Line Leak Detector. Model: LD-2000 S Mechanical Line Leak Detector. Model: LD-3000 0 Electronic Line Leak Detector. Model: I Electronic Line Leak Detector. Model: 0 Tank Overfill/High-Level Sensor. Model: DROP TUBE VALVE Tank Overfill/High-Level Sensor. Model: DROP TUBE VALVE 0 Others equipment and model in Section E on Page 2). --j Others �e uigment!ype and model in Section E on Pae 2). Tank ID: TANK 2 SUPER UST Tank ID: TANK 5 AST EAST • In-Tank Gauging Probe. Model: MAG 1 0 In-Tank Gauging Probe. Model: MAO I 0 Annular Space or Vault Sensor. Model: 420 0 Annular Space or Vault Sensor. Model: 420 - • Piping Sump/Trench Sensor(s). Model: 208 [9 Piping Sump/Trench Sensor(s). Model: 208 [i Fill Sump Sensor(s). Model: - Fill Sump Sensor(s). Model: ED Mechanical Line Leak Detector. Model: LD-2000 Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: 0 Tank Overfill/High-Level Sensor. Model: DROP TUBE VALVE Tank Overfill/High-Level Sensor. Model: 0 Other LsLeciN.2�Uiment!yg2 and model in Section E on Page 2). = Other LS222!N 2quipment M and model in Section E on Page 21 Tank ID: TANK 3 DIESEL WEST UST Tank ID- TANK 6 AST WEST S In-Tank Gauging Probe. Model: MAG I Z In-Tank Gauging Probe. Model: MAG 1 0 Annular Space or Vault Sensor. Model: 420 0 Annular Space or Vault Sensor. Model: 420 & Piping Sump/Trench Sensor(s). Model: 208 CR Piping Sump/Trench Sensor(s). Model: 208 0 Fill Sump Sensor(s). Model: -_ Fill Sump Sensor(s). Model: 9 Mechanical Line Leak Detector. Model: LD-2000 = Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: 0 Tank Overfill/High-Level Sensor. Model: DROP TUBE VALVE Tank Overfill/High-Level Sensor. Model: 0 Other(s[Leci!y equipment lype and model in Section E on Page 2). E Other(speci!y equipment pe and model in Section E on Page 2). Dispenser ID: Dispenser ID: o Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: Ei Shear Valve(s). Shear Valve(s). El Dispenser Containment Floats)and,Chaln(s). Dispenser Containment Float(s)and Chains . Dispenser ID: I THRU 8 Dispenser ID: 11THRUI8 - 0 Dispenser Containment Sensor(s). Model: Dispenser Containment Sensoqs). Model: 0 Shear Valve(s). Shear Valve(s). 0 DisELenser Containment Floats)and Chains 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 inspectediserviced in accordance with the manufacturers' guidelines. Attached to this Certification is Information(e.g.manufacturers'checklists)necessary to*rIfy that this information Is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of e n such reports,I have also attached a copy of the report;(check ail that apply): 0 System set-up 9 Alarm history report Technician Name(print): GREG KAISER Signature: Certification No.: A25993 License.No.: /8 Testing Company Name: KAISER_COMMERCIAL PETROLEUM I one No.: 209 ) 887-2639 Testing Company Address: PO 1 58,LINDEN,CA 95236 V Date of Testing/Servicing: 04 29 2015 _E BOX 0 Monitoring System Certification Page I of 4 12f07 2/21/07