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C Appendix VI SEP 21 2015 (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http:// .waterboards.ca.gov.) MONITORING SYSTEM CERTIFICATION I� ENVIRONMENTAL 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 UST systems within 30 days of test date. A. General Information Facility Name: Mid City Ca FO Re -gen Bldg. No.: KINGCA Site Address: 13850 Devries Road City: Lodi Tap: 95242 Facility Contact Person: Jonathan Pakele Contact Phone No.: 916-439-6042 Make/Model of Monitoring System: Pnuemercator TMS 2000 Date of Testing/Servicing: 09/03/15 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment ins ected/serviced: Tank ID: UST#313/DieseV550 gallons Tank ID: u In -Tank Gauging Probe. Model: MP -450 Cl In -Tank Gauging Probe. Model: Ll Annular Space or Vault Sensor. Model: LS -610 a Annular Space or Vault Sensor. Model: u Piping Sump/ Trench Sensor(s). Model: LS -600 Cl Piping Sump/ Trench Sensor(s). Model: a Fill Sump Sensor(s). Model: a Fill Sump Sensor(s). Model: O Mechanical Line Leak Detector. Model: a Mechanical Line Leak Detector. Model: O Electronic Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: 0 Tank Overfill / High -Level Sensor. Model: mechanical/RA-200 O Tank Overfill / High -Level Sensor. Model: o Other ecify equipment a and model in Section E on Pae 2). O Other s ea equipment t e and model in Section E on Pa e 21. Tank ID: Tank ID: a In -Tank Gauging Probe. Model: Ct In -Tank Gauging Probe. Model: O Annular Space or Vault Sensor. Madel: O Annular Space or Vault Sensor. Model: 0 Piping Sump / Trench Sensor(s). Model: ® Piping Sump / Trench Sensor(s). Model: [3 FII Sump Sensor(s). Model: a Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: 13 Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: Ct Tank Overfill / High -Level Sensor. Model: Ct Other(specify a ui ment a and model in Section E on Pae 2). 0 Other (specj!X a ui ment tyge and model in Section E on Pa e 2). Dispenser ID: DispenseriD: ® Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model: Ct Shear Valve(s). la Shear Valve(s). ® Di§penser Containment Floats and Chain(s). Ef Dispenser Containment Floats and Chain(s). Dispenser ID: Dispenser ID: O Dispenser Containment Sensor(s). Madel: 0 Dispenser Containment Sensor(s). Model: O Shear Valve(s). a Shear Valve(s). d Dispenser Containment Floats and Chain(s). O Dispenser Containment Floats and Chain(s). Dispenser ID: Dispenser ID: Ct Dispenser Containment Sensor(s). Model: Ct Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ® Shear Valve(s). ® Dispenser Containment Floats and Chains O Dis enser Containment Floats 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 /smiced 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 ofnerati such reports, I have also attached a copy of the report; (check all that apply): 0 System set-up � Alarm history reportD� �y s�n� b)u�n Becera for WT#1 N6 423 Technician Name (print): Ruben Becerra Signature: 091031x1151125;49 Certification No.: 10993/5302139 License. No.: 703190 Testing Company Name: Sunwest engineering inc. Phone No.: 8( 88 ) 588-8737 Testing Company Address: 4780 Cheyenne way, Chino CA 91710 Date of Testing/Servicing: 09/03/15 Monitoring System Certification QA/QC APPROVED 9/15/20153:19 Mustin Tre Wednesday, September 16, 2015 brittanyl Page 1 of 4 12107 2/21/07