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Appendix VI APR 0 2 2014 (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://S vrcb.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 #208117 Bldg. No.: Site Address: 755 S. TRACY BLVD Facility Contact Person: MGR - MARIA City: TRACY Contact Phone No.: 209-830-0370 Make/Model of Monitoring System: Veeder Root TLS -350 B. Inventory of Equipment Tested/Certified Check the aoorooriate boxes to indicate soecific eauioment inspected /serviced: Zip: 95376 Date of Testing/Servicing: 3/3/2014 Tank ID: T 1 - PREMIUM Tank ID: In -Tank Gauging Probe. Model: mag In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 409 r7 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: Veeder Root PLLD r Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: flapper Tank Overfill / High -Level Sensor. Model: 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: T 2 - REGULAR Tank ID: In -Tank Gauging Probe. Model: mag In -Tank Gauging Probe. Model: ry Annular Space or Vault Sensor. Model: 409 r Annular Space or Vault Sensor. Model: Wo 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: I- Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: rV Electronic Line Leak Detector. Model: Veeder Root PLLD r Electronic Line Leak Detector. Model: Wo Tank Overfill / High -Level Sensor. Model: flapper Tank Overfill / High -Level Sensor. Model: 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). Dispenser 1/2 Dispenser 7/8 ID: ID: rV Dispenser Containment Sensor(s). Model: 208 r' Dispenser Containment Sensor(s). Model: 208 W Shear Valve(s). f%_0 Shear Valve(s). Dispenser Containment Float(s) and Chain(s). r Dispenser Containment Float(s) and Chain(s). Dispenser 3/4 Dispenser 9/10 ID: ID: rV Dispenser Containment Sensor(s). Model: 208 Wo Dispenser Containment Sensor(s). Model: 208 ri, Shear Valve(s). Shear Valve(s). r Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser 5/6 Dispenser 9/10 ID: ID: rV Dispenser Containment Sensor(s). Model: 208 . Dispenser Containment Sensor(s). Model: 208 r 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 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): P System set- up W Alarm history report Technician Name (print): Timothy Elebeck Certification No.: 835252 Testing Company Name: Tanknology Signature: License. No.: 743160 Class'A' Phone No.: (800) 800.4633 Testing Company Address: 11000 N. MoPac Expressway Suite 500 Date of Testing/Servicing Monitoring System Certification Page 1 of 3 3/3/2014 12/07