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0 <br /> 0 RECEIVED <br /> Appendix V1 MAY 112015 <br /> (Copies of Monitoring system Certification form and UST Monitoring Plot Plan available at Rhttg:11www.ft""ks.ca­gov.) <br /> PERMIT/SF[AALHEALTH <br /> MONITORING SYSTEM CERTIFICATION cEs <br /> For Use By All Jurisdictions Within the State of Calittimia <br /> Authority Cited. Chapter 6.7, Health and Safety Code;Chapter 16, Division 3, Title 23, California Code of <br /> Regulations <br /> This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be prepared for <br /> each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system <br /> 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. <br /> A. General Information Bldg.No.: <br /> Facility Name: TRACY TRUCK&AUTO <br /> Site Address: ;M N.TRACY BLVD. City:_TRACY Zip: 95304 <br /> Facility Contact Person: DEBBIE AND CJ Contact Phone No.: <br /> Make/Model of Monitoring System: TLS EMC 360 Date of Testing/Servicing: 04 1_2L/ 2016 <br /> B. Inventory of Equipment Tested/Certified <br /> Check the amoeriats boxes to indicate senific uI ment ins serviced: <br /> Tank FID: TANK I REG NL UST Tank ID: TANK 4 DIESEL EAST UST <br /> 0 In-Tank Gauging Probe. Model:_MAG 1 0 In-Tank Gauging Probe. Model: MAG I <br /> Model: 408 <br /> IR <br /> 0 Annular Space or Vault Sensor. Model: 408 0 Annular Space or Vault Sensor. <br /> 0 0 Piping <br /> Su p, to Piping Sump/Trench Sensor(s). Model: 201 <br /> Piping Sump/Trench Sensor(s). Model:::20_-8— <br /> S Model: <br /> 0 Fill Sump Sensor(s). Model: Sump Sensor(s). <br /> 23 Mechanical Line Leak Detector. Model: LD-2000 0 Mechanical Line Leak Detector. Model: LD-30M <br /> 0 Electronic Line Leak Detector. Model:_ 0 Electronic Line Leak Detector. Model:-- <br /> E9 Tank Overfill/High-Level Sensor. Model: DROP TUBE VANE— g Tank Overfill/High-Level Sensor. Model: 2fflP TUBE VALVE <br /> 0 Other(slLeci!X equipment!Me and model in Section E on Pa 22?J. 0 Other(scieq! model in Section E on Page?J. <br /> p2 !y !!pment�2,e and .. <br /> Tank ID: TANK 2 SUPER UST Tank ID: TANK 5 AST T <br /> • In-Tank Gauging Probe. Model: MAG 1 0 In-Tank Gauging Probe. Model: MAG.I <br /> • Annular Space or Vault Sensor. Model: 408 0 Annular Space or Vault Sensor. Model:, 408 <br /> • Piping Sump/Trench Sensor(s). Model: 208 0 Piping Sump I Trench Sensor(s). Model: 208 <br /> 11 Fill Sump Sensor(s). Model: -1 Fill Sump Sensor(s). Model: <br /> N Mechanical Line Leak Detector. Model: LD-2009 L7 Mechanical Line Leak Detector. Model: <br /> 0 Electronic Line Leak Detector. Model: E, Electronic Line Leak Detector. Model: <br /> 0 Tank Overfill/High-Level Sensor. Model: DROP TUBE VAQffi 0 Tank Overfill/High-Level Sensor. Model: <br /> 11 Other�sp2ci!j equiEM21D�"eand model in Section E on Pa e 2. 0 Other Lspe5g!quipment!0 and model In Section E on Pa e 2). <br /> 0 L.. =6-4 <br /> Tank ID: TANK 3 DIESEL WEST,UST Tank ID: TANK 6 AST WEST <br /> • In-Tank Gauging Probe. model: -MAG I Z in-Tank Gauging Probe. Model: MAG I <br /> I <br /> N Annular Space or Vault Sensor. Model: 408 <br /> • Annular Space or Vault Sensor. Model: 408 1 r" <br /> • Piping Sump/Trench Sensor(s). Model: 208 0 Piping Sump/Trench Sensor(s). Model: 208 <br /> 0 Fill Sump Sensor(s). Model: <br /> 11 Fill Sump Sensor(s). Model: <br /> 0 Mechanical Line Leak Detector. Model: LD-2000 0 Mechanical Line Leak Detector. Model: <br /> 0 Electronic Line Leak Detector. Model: :1 Electronic Line Leak Detector. Model: <br /> 0 Tank Overfill/High-Level Sensor. Model: DROP TUBE VALVE ❑ Tank Overfill/High-Level Sensor. Model: <br /> o Other(snd model in Section E on Page <br /> p2ga gguip2!ent�Te and model in Section E on Page 13 Other(specify equipmart!ype a <br /> Dispenser ID: Dispenser ID: <br /> 0 Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: <br /> 0 Shear Valve(s). D Shear Valve(s). <br /> 11 Desnser Containment Floats and Chainjsj. Li Dispenser Containment Floatsj and ChainN., <br /> Dispenser ID:_1 THRU 8 Dispenser ID: IITHRU18 <br /> 0 Dispenser Containment Sensor(s). Model: D Dispenser Containment Sensor(s). Model: <br /> • Shear Valve(s). 0 Shear Valve(s). <br /> • gispenser,Containment Floats)and,Chains 0 Dispenser Containment Floats and Chain�sj. <br /> *If the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility. <br /> C. Certification - I certify that the equipment identified in this document was Inspected/serviced In accordance with the manufacturers' <br /> guidelines. Attached to this Certification Is Information(e.g.manufacturers'checklists)necessary to verify that this Information Is correct <br /> and a Plot Plan showing the layout of monitoring equipment For any equipment capable of gen ting such reports,I have also attached a <br /> copy of the report,(check all that apply): N System set-up 0 Alarm history report <br /> Technician Name(print): GREG KAISER Signature: <br /> Certification No.: 69M- License.No.: a <br /> 887-2639 <br /> Testing Company Name: KAIgg&CQMMERCIAL PETROLEUM -W4 No.: 209 <br /> Testing Company Address:_egjqg-X_j0-5-8-,LINDEN,CA 91236 Date of Testing/Servicing:04 2015 <br /> Monitoring System Certification Page 1 of 4 12107 <br /> 2/21/07 <br />