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11 Appendix VI 11 (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://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 Make/Model of Monitoring System: Veeder Root TLS350 B. Inventory of Equipment Tested/Certified Contact Phone No.: 477-4294 Date of Testing/Servicing: 2/1/2013 Tank ID: T1 - SUPREME Tank ID: regular 1 - REGULAR rv, In -Tank Gauging Probe. Model: Mag ry In -Tank Gauging Probe. Model: Mag Annular Space or Vault Sensor. Model: 407 W, Annular Space or Vault Sensor. Model: 407 ry Piping Sump / Trench Sensor(s). Model: 352 W Piping Sump / Trench Sensor(s). Model: 352 r' Fill Sump Sensor(s). Model: 208 r Fill Sump Sensor(s). Model: 208 Mechanical Line Leak Detector. Model: r Mechanical Line Leak Detector. Model: ', Electronic Line Leak Detector. Model: Veeder Root PLLD ', Electronic Line Leak Detector. Model: Veeder Root PLLD W Tank Overfill / High -Level Sensor. Model: Flapper Tank Overfill / High -Level Sensor. Model: Flapper Other(specify equipment a and model in Section E on Pa e 2). r 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 r Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: 352 r Piping Sump / Trench Sensor(s). Model: Wo Fill Sump Sensor(s). Model: 208 r 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: r'' Tank Overfill / High -Level Sensor. Model: Flapper r Tank Overfill / High -Level Sensor. Model: Other(specify equipment a and model in Section E on Pae 2). Other(specify equipment a and model in Section E on Pae 2 . Dispenser 1/2 Dispenser 3/4 ID: ID: rV Dispenser Containment Sensor(s). Model: 208 Dispenser Containment Sensor(s). Model: 208 r' Shear Valve(s). r Shear Valve(s). Dispenser Containment Float(s) and Chain(s). r Dispenser Containment Float(s) and Chain(s). Dispenser 5/6 Dispenser 7/8 ID: ID: Dispenser Containment Sensor(s). Model: 208 Dispenser Containment Sensor(s). Model: 208 Shear Valve(s). r1 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: 208 rYO Dispenser Containment Sensor(s). Model: 208 17 Shear Valve(s). rvO Shear Valve(s). r 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 form. Include information tor every tanK ana aispenser at the racurcy. 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): Joey Mesa Certification No.: A27796 Testing Company Name: Tanknology License. No Signature: .: 743160 Class'A' Phone No.: (800) 800-4633 Testing Company Address: 11000 N. MoPac Expressway Suite 500 Date of Testing/Servicing: 2/1/2013 Monitoring System Certification Page 1 of 3 12/07