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Appendix VI ( Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http : //www, waterboards . 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: Arco Bldg . No . : Site Address : 1904 daniels St . City: Manteca Zip : 95337 Facility Contact Person : Contact Phone No. : Make/Model of Monitoring System : TLS-350R Dale of Testing/Seryicing : 4- 17-2018 B . Inventory of Equipment Tested/Certified Check thea ro riate boxes to indicatespecific equipment ins ected/seryiced : Tank ID : 87 Unleaded Tank ID : Diesel ® In -Tank Gauging Probe . Model : 847390- 109 ® In-Tank Gauging Probe. Model : 847390- 109 ® Annular Space or Vault Sensor. Model : Hydrostatic ® Annular Space or Vault Sensor, Model : Hydrostatic ® Piping Sump / Trench Sensor(s ) . Model : 794380-208 ® Piping Sump / Trench Sensor(s ) , Model : 794380-208 ® Fill Sump Sensor(s ) . Model : 794380-208 ® Fill Sump Sensor(s ), Model : 794380-208 ❑ Mechanical Line Leak Detector. Model : ❑ Mechanical Line Leak Detector. Model : ® Electronic Line Leak Detector. Model : 8484 ® Electronic Line Leak Detector, Model : 8484 ® Tank Overfill / High- Level Sensor. Model : 847390- 109 W/Buzzer ® Tank Overfill / High-Level Sensor. Model : 847390- 109 W/Buzzer ❑ Other (specify equipment t e and model in Section E on Page 2 ) . ❑ Other (specify equipment t e and model in Section E on Page 2). Tank ID : 91 Premlum Tank ID : ® In -Tank Gauging Probe , Model : 847390- 109 ❑ In-Tank Gauging Probe . Model : ® Annular Space or Vault Sensor. Model : Shares Diesel ❑ Annular Space or Vault Sensor. Model : ® Piping Sump / Trench Sensor(s ) . Model : 794380-208 ❑ Piping Sump / Trench Sensor(s) . Model : ® Fill Sump Sensor(s ) , Model : 794380-208 ❑ Fill Sump Sensor(s ) . Model : ❑ Mechanical Line Leak Detector. Model : ❑ Mechanical Line Leak Detector. Model : ® Electronic Line Leak Detector, Model : 8484 ❑ Electronic Line Leak Detector. Model : ® Tank Overfill / High -Level Sensor. Model: 847390- 109 W/Buzzer ❑ Tank Overfill / High- Level Sensor. Model : ❑ Other (specify equipment t e and model in Section E on Page 2 ), ❑ Other ( specify e ui ment type and model in Section E on Page 2) . Dispenser ID : 1 -2 Dispenser ID : 3-4 ® Dispenser Containment Sensor(s) . Model : 794380-208 ® Dispenser Containment Sensor( s) . Model : 794380-208 ® Shear Valve(s) . ® Shear Valve( s ) . ❑ Dispenser Containment Float(s) and Chain(s ) . ❑ Dispenser Containment Floats and Chain (s). Dispenser ID: 5-6 Dispenser ID : 7-8 ® Dispenser Containment Sensor(s ) . Model : 794380-208 ® Dispenser Containment Sensor(s) . Model : 794380-208 ® Shear Valve(s) . ® Shear Valve(s) . ❑ Dispenser Containment Floats and Chain (s). I ❑ Dispenser Containment Floats and Chain (s). Dispenser ID : 9- 10 Dispenser ID : 11 - 12 ® Dispenser Containment Sensor(s ) . Model : 7984380-208 2 Dispenser Containment Sensor(s) . Mode1794380-208 ® Shear Valve(s) . ® Shear Valve(s ) . ❑ Dispenser Containment Floats and Chains ! ❑ Dispenser Containment Floats 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) : Brian Roth Signature : Certification No . : A29956License , No. : 949066 Testing Company Name: Nucleus Pump Services Phone No . : (916 ) Testing Company Address : 601 First Ave . Sacramento Ca . Date of Testing/Servicing : Monitoring System Certification Page 1 of 4 12/07 1 2/21 /07