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� • RECEIVED Appendix VI JL 0 8 2015 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, Californi OUROWMENTAL This form must be used to document testing and servicing of monitoring equipment. A separate certification or reportTAA R T each monitoring system control panel by the technician who performs the work. A copy of this form must be provided o 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: HAMMER LANE OIL CHEVRON Bldg. No.: Site Address: Facility Contact Person: 3304 W HAMMER LANE City: STOCKTON CA Make/Model of Monitoring System: VEEDER ROOT B. Inventory of Equipment Tested/Certified Check the annronriate, boxes to indicates ecific a ui ment ins ected/serviced: Contact Phone No.: Zip: Date of Testing/Servicing: 6/10/2015 Tank ID: 87 Tank Size: Tank ID: 91 Tank Size: ® In -Tank Gauging Probe. Model: MAG 1 ® In -Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 420 ® Annular Space or Vault Sensor. Model: SPLIT W DSL 420 ® Piping Sump / Trench Sensor(s). Model: 208 ® Piping Sump / Trench Sensor(s). Model: 208. ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: FE PETRO ® Mechanical Line Leak Detector. Model: FE PETRO ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: DIE Tank Size: Tank ID: Tank Size: ® In -Tank Gauging Probe. Model: MAG 1 ❑ In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: SPLIT W 91 420 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump/ Trench Sensor(s). Model: 208 ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: RED JACKET D ❑ 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 (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: 1-2 Dispenser ID: 5-6 Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ® Shear Valve(s). XDispenser Containment Float(s) and Chain(s). X Dispenser Containment Float(s) and Chain(s). Dispenser ID: 3-4 Dispenser ID: 7-8 Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ® Shear Valve(s). X Dispenser Containment Float(s) and Chain(s). X Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(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 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 Pian showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the report; (check all that apply): ® System set-up ❑ Alarm history report Technician Name (print): David Winkler Signature: 4 ""—,) Certification No.: 5263373 -UT License No: 08-1739 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0112 Testing Company Address: 416 Z STREET GALT, CA 95632 Date of Testing/Servicing: 6-10-15 Monitoring System Certification Page 1 of 4 2/21/07