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Sep. 5. 2018 3i52PM Donlee Pump Co No. 0571 Appendix VI (Copies of Monitoring System Cellilication form and UST Monitoring Plot Plats available at http://www.waterboards.ca.aov1) MQNI I VKING SYSTEM CERTINUATIVN FWe or Use By All Jurlsdlctions Within fhe Slate of California Atlfhva 14Y Clfed: Chapter 6 7, Ne94 and Sglfety Cade; Chapter 16, Dilrision 3, TINe 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 ownerloperator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within St) days of test date. A. General Information Facility Name; MRM Arch Rd. Cardlock Bldg, No.; Site Address; 4733 S. Hyiy99 Frontage Rd. City: Stockton zip; Facility Contact Person; RiCb FrtrtFriCk„SpD Contact Phone Nov, ( 209 }517-0723. Make/Model o1 Monitoring System: TLS -350 Date of Tosfing/Servlcing; 9I,I,�Q� $ B. Inventory of Equipment Teeted/Certilled Check the appropriate boxes to Indicatespecific equipment ins acted/serviced: Tank iD! Tank IDA 0 brTank Gauging Probe. Model ❑ In•Tank Gauging Probe, Modal: D Annular Space or Vault Sensor, Model: 0 Annular Space or Vault Sensor, Model: 0 Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model; 0 Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: 0 Etecironlo Una Leak Detector, Mode): 0 Electronic Line Leak Detector. Model: ❑ Tank Overfill / Hfgh•Level Sensor. Model; 0 Tank Overfill / Htgh-Level Sensor, Model: 0 Other (specify s ul ment type and model in Section F. on Pago 2), 0 Olher (specify equipment t e And model In Section E on Page 2). Tank IDA Tank 10: ❑ in -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model; ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model 0 Piping Sump / Trench Sansor(s). Model; ❑ Fill Sump Sensors). Model: __ 0 Fill Sump Samor(s). Model: ❑ Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: 0 Electronic Line Leak neteolor. Model: 0 Electronic Una Leak Detector. Model; ❑ Tank Overfill / High•l.evet Senmr, Model: 0 Tank Overfill / HIghiLevel Sensor. Model: ❑ Other (specify a ui mens too and model in Section E on Page 2). ❑ Other 6 of a ui mens t a and model in Section Evvvvv on DlspenserlD: "vvvDispenser 10: K. Dispenser Containment Sensor(s), Model: VRA, ZP 0 Dispenser Containment Sensor(s). Model; @:a Shear Valve(s). 0 Shear Valve(s). ❑ Dispenser Conlalnmenl Floats and Chains . 0 Dispenser Containment Ftoal s and Cham s . Dispenser Ib; Dlaponser ID: WWW_ ❑ Dispenser Containment Sensor(s). Model; ❑ Dispenser Conlainmenl Sensor(s). Model; ❑ Shear Vatva(s). D Shear Valve(s). ❑ Dispenser Conlainn ont Flo t s and Chains . 0 Dispenser Containment Floats and Chain(s). Dispenser ID: Dispenser ID; ❑ Dispenser Containment Sensor(s). Model; ❑ Otspenser Conlainmenl Sensot(s). Model: ❑ Shear Valve(s), 0 Shear Valve(s). 0 Dispenser Containment Floalls) and Chains 0 Dispenser Containment rloal(s) and Chaln(s). 'ff the facility r,6nlefns more lanks or dispensers, Dopy this forRi, Include Information for every lank and dispenser at the iacilily. C. Cerilileatlon - i aartlfy that the equipment Identified in this document was inspeetedlserviced In accordance with the manufacturers' guidelines. Attached to this Certification Is Information (e.g. manufacturers' checkllsts) necessary to verity that this Information to correct and a Plot Plan showing the layout of moriltorin equipment. For any equlgFenl capable of ganeraorig such reports, I have also Attached a copy of the report; (chookall that apply); Syslam sehup >eAl ryystory report mmme Technlclan Name (print): , f�,0.#h�,'1ny (pivaG Signature; Ce►tilloat►on No.: Oe�3 j,n2 Lleanss. No.: 000i)qR4 , „ Testing Company Name: --D 41ge pLIMp CippApagy.. Phone No.:( 20A 1 5.17-4' 96 TosUrC CompanyAddress; 2895 RaIJFoadAyO, Date of Tosting/Sarvicing: 9 A 190I$_ _ Mcnlloring System Cerditcatlon 12loi 2/21/p7