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Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at hftp://www.swrcb.ca.gov.) 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 UST systems within 30 days of test date. A. General Information Facility Name: CHEVRON # 96171 (N-621-1-3) Bldg. No.: Site Address: 6633 PACIFIC AVE City: STOCKTON Zip: 95207 Facility Contact Person: MGR - SUE LYNN Contact Phone No.: 209-477-4294 Make/Model of Monitoring System: Veeder Root TLS350 Date of Testing/Servicing B. Inventory of Equipment Tested/Certified n:.....:. r:... ..r..:... .. w.. ...1:..ar.. ..a:.. e..� : e..►ed /tee......®d. 1/30/2014 Tank ID: TI - SUPREME Tank ID: regular 1 - REGULAR ry In -Tank Gauging Probe. Model: mag r'., In -Tank Gauging Probe. Model: mag Annular Space or Vault Sensor. Model: 407 rj Annular Space or Vault Sensor. Model: 407 177 Piping Sump / Trench Sensor(s). Model: 352 P Piping Sump / Trench Sensor(s). Model: 352 Fill Sump Sensor(s). Model: 208 �v', Fill Sump Sensor(s). Model: 208 r Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Veeder Root PLLD r', Electronic Line Leak Detector. Model: Veeder Root PLLD Tank Overfill / High -Level Sensor. Model: flapper W Tank Overfill / High -Level Sensor. Model: flapper Other(specify equipment a and model in Section E on Page 2). Other(specify equipment a and model in Section E on Pae 2). Tank ID: regular 2 - REGULAR Tank ID: In -Tank Gauging Probe. Model: mag r In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 407 Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: 352 r Piping Sump / Trench Sensor(s). Model: Fill Sump Sensor(s). Model: 208 [ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: r Electronic Line Leak Detector. Model: W. Tank Overfill / High -Level Sensor. Model: flapper r Tank Overfill / High -Level Sensor. Model: s Other(specify equipment a and model in Section E on Page 2). ri Other(specify equipment a and model in Section E on Pae 2). Dispenser 1/2 Dispenser 3/4 ID: ID: r Dispenser Containment Sensor(s). Model: 208 rd Dispenser Containment Sensor(s). Model: 208 rV_' Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser 5j6 Dispenser 7/8 ID: ID: ry Dispenser Containment Sensor(s). Model: 208 rV Dispenser Containment Sensor(s). Model: 208 Shear Valve(s). rvl Shear Valve(s). Dispenser Containment Float(s) and Chain(s). r Dispenser Containment Float(s) and Chain(s). Dispenser 9/10 Dispenser 11/12 ID: ID: Dispenser Containment Sensor(s). Model: 208i Dispenser Containment Sensor(s). Model: 208 Shear Valve(s). rYO Shear Valve(s). Dispenser Containment Float(s) and Chain(s). r Dispenser Containment Float(s) and Chain(s). *If the facility contains more tanks or dispensers, copy this torm. Include intormation 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 Plan 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): W System set- up W Alarm history report Technician Name (print): Jarrod Cooke Certification No.: 33235 Testing Company Name: Tanknology Signature:�� License. No.: 743160 Class'A' Phone No.: (800) 800-4633 Testing Company Address: 11000 N. MoPac Expressway Suite 500 Monitoring System Certification Page 1 of 3 Date of Testing/Servicing: 1/30/2014 12/07