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Appendix VI 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 tan k 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: MISSION - ABC PETROLEUM TRACY TEXACO Bldg, No. : Site Address: 2376 TRACY BLVD City: TRACY Zip: 96376 Facility Contact Person : HAKAM Contact Phone No. : (209) 836-6358 Make/Model of Monitoring System: VEEDER ROOT TLS 360 Date of Testing/Servicing: 09-10-18 B. Inventory of Equipment Tested/Certified Check the appro nate boxes to indicatespecific equipment inspected/serviced : Tank ID : 87 Tank ID : DIE ® In-Tank Gauging Probe, Model : MAG ® In-Tank Gauging Probe, Model : MAG ® Annular Space or Vault Sensor, Model : 407 ® Annular Space or Vault Sensor. Model : 407 ® Piping Sump / Trench Sensor(s), Model : 208 ® Piping Sump / Trench Sensor(s). Model : 208 ❑ Fill Sump Sensor(s). Model : ❑ Fill Sump Sensor(s). Model : ® Mechanical Line Leak Detector, Model : LD 2000 ® Mechanical Line Leak Detector. Model : LD 2000 ❑ Electronic Line Leak Detector. Model : ❑ Electronic Line Leak Detector. Model : ® Tank Overfill / High-Level Sensor. Model : FLAPPER ® Tank Overfill / High-Level Sensor. Model : FLAPPER ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID : 91 Tank ID : WASTE OIL ® In-Tank Gauging Probe. Model : MAG ❑ In-Tank Gauging Probe. Model : ® Annular Space or Vault Sensor, Model : 407 ® Annular Space or Vault Sensor. Model : 407 ® Piping Sump / Trench Sensor(s). Model : 208 ❑ Piping Sump / Trench Sensor(s). Model : ❑ Fill Sump Sensor(s). Model : ❑ Fill Sump Sensor(s). Model : ® Mechanical Line Leak Detector, Model : LD 2000 ❑ Mechanical Line Leak Detector. Model : ❑ Electronic Line Leak Detector. Model : ❑ 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), Dispenser ID: 1 -2 Dispenser ID : 34 ® Dispenser Containment Sensor(s). Model : 332 ® Dispenser Containment Sensor(s), Model : 332 ® ShearValve(s) , ® ShearValve(s), ❑ Dispenser Containment Float(s) and Chain (s). ❑ Dispenser Containment Float(s) and Chain(s) . Dispenser ID: 3-4 Dispenser ID: J=6 ® Dispenser Containment Sensor(s). Model : 332 ® Dispenser Containment Sensor(s), Model : 332 ® ShearValve(s). ® ShearValve(s). ❑ Dispenser Containment Float(s) and Chain(s) . ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID : Dispenser ID: ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s), Model : Sensor(s) . Model : ❑ ShearValve(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): ® System set-up ® Alarm history report Technician Name (print): FELIX RAMIREZ Signature: —z� Certification No. : 8883072-UT License No: 08-1740 Testing Company Name: AFF0RDA-TESTT Phone No. (209) 744-0113 Testing Company Address: 416 2"a STREET GALT, CA 95632 Date of Testing/Servicing : 09-10-18 Monitoring System Certification Pagel of 4 2/21 /07