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Appendix VI RECDNED MONITORING SYSTEM CERTIFICATION -7- 6 2018 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 r�GPpqq epared for each monitoring system control panel by the technician who performs the work.A copy of this forth must be pr$04 =(system `.:_ HEALTH Owner/operator.The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 d�ygof test date. _NTA. General Information: I-` Facility Name: TRACY BLVD CHEVRON Bldg.No.: Site Address: 3775 TRACY BLVD City: TRACYCA Zip: 95376 Facility Contact Person: Contact Phone No.: ( ) Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 2116/2018 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment ed/serviced: Tank ID: 87 Tank Size: Tank ID: 91 Tank Size: N In-Tank Gauging Probe. Model: MAG 1 ❑ In-Tank Gauging Probe. Model: MAG 1 N Annular Space or Vault Sensor. Model: 409 N Annular Space or Vault Sensor. Model: 409 N Piping Sump/Trench Sensogs). Model: 208 N Piping Sump/Trench Sensor(s). Model: 208 N Fill Sump Sensor(s). Model: 208 N Fill Sump Sensor(s). Model: 208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: N Electronic Line Leak Detector. Model: PLLD N Electronic Line Leak Detector. Model: PLLD ❑ Tank Overfill/High-Level Sensor. Model: FLAPPER ❑ Tank Overfill/High-Level Sensor. Model: FLAPPER ❑ Other(specify equipment type and mo del in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). Tank ID: DIE Tank Size: Tank ID: Tank Size: N In-Tank Gauging Probe. Model: MAG 1 ❑ In-Tank Gauging Probe. Model: N Annular Space or Vault Sensor. Model: 409 ❑ Annular Space or Vault Sensor. Model: N Piping Sump/Trench Sensor(s). Model: 208 ❑ Piping Sump/Trench Sansone). Model: N Fill Sump Sensons). Model: 208 ❑ Fill Sump Sensor(s). Madel: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: N Electronic Line Leak Detector. Model: PLLD ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: FLAPPER ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). DispenserlD: 1-2 Dispenser ID: 7.8 N Dispenser Containment Sensor(s). Model: 208 N Dispenser Containment Sensor(s). Model: 208 ® Shear Valve(s). N Shearvalve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). DispenserlD: 3-4 DispenserlD: 9-10 N Dispenser Containment Sensor(s). Model: 208 N Dispenser Containment Sensor(s). Model: 208 N Shear Valve(s). N Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). DispenserlD: 5.6 DispenserlD: 11-12 ® Dispenser Containment N Dispenser Containment Sensor(s). Model: 208 Sensor(s). Model: 208 N Shear Velvets). N Shear Valve(s). ❑ Dispenser Containment Float(s)and Cham(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): N System set-up N Alarm history report Technician Name(print): David Wnkler Signature: Certification No.: 5263373-UT License No: 08-1739 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0112 Testing Company Address: 418 2nd STREET GALT CA 95632 Date of Tesfing/Servicing: 2-16-18 Monitoring System Certification Page 1 of 4 2/21/07