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130620-293 Appendix V1 (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.waterboards.ca.g MONITORING SYSTEM CERTIFICATION For Use By All Judsoldihns Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code, Chapter 16, Division 3, 77116 23, California Code of Regulations This farm 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 INS 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: Manteca CO Sklo. No.: CA4784419 site Awrew. 430 W. Center Street city: Manteca - zip: 95336 Faculty contact Person: Vincent Scheaffer - Contact Phone No.: 209-401-4547 Makwodel of Monitoring System: Veeder Root TLS -350 Date of TestkVServIdng: 8-6-13 C. Certification - I caft that the equipment Identified In this document was Inspected/serviced In accordance with the manufachirers' guidelines. Attached to title Certiftailort Is f (e g. menufactureW chaddists) necessary to verify thm Oft Infonnation Is correct artil a Plot Plan showing the Wyatt of monitoring oWlipmeriL For any 9WIpment capab P! emu Stich repo"s I Ihav als; attached a en I copy of the report; (check aff that *ply). B System set-up B Alarm history report ggp�l nedo7panc�naMR593 y Technician Name (print): Paul McLane Signature: Certification No.: 8191873 -UT License. No.: 703190 Testing Company Name: Sunwest Engineering Inc. Phone No.:(_909 ) 594-9850 Testing company Address: 2766 Pomona Blvd. Pornona,rn Ca. 91768 Date of Towngiservicing: 8-6-13 Monitoring System Certification Pop 1 of 4 12/07 QA/QC APPROVED 8/9/201310:31 AMIMike P. B 2121/07