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Il�)�CEIIVED Appendix V1 NOV 0 5 2018 (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at htt ://www,waterboards.ca. ov. ENVIRONNIENVAL EALT11 MONITORING SYSTEM CERTIFICATION [DEPARTMENT 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. Generallnformation Facility Name: _Ramos Oil Company Bldg. No.: site Address: _10842 S. Harlan Road city: _French Camp zip: Facility Contact Person: _Steve RlChardSOn Contact Phone No.:916-371-2570 Make/Model of Monitoring System: _TLS -35O Date of Testing/Servicing: _1 O/25�18 B. Inventory of Equipment Tested/Certified 'Ii the facility contains more tanks or dispensers, copy this form. Include information for every Check the appropriate boxes to indicate specific a uipment ins ected/serviced: Tank ID: Diesel Tank ID: x _1 In -Tank Gauging Probe. Model: 1 ❑ In -Tank Gauging Probe. Model x Annular Space or Vault Sensor. Model: _Mag 303 ❑ Annular Space or Vault Sensor. Model: x Piping Sump /Trench Sensor(s). Model: _VR VR 208 ❑ Piping Sump / Trench Sensor(s). Model: x Fill Sump Sensor(s). Model: VR 208 ❑ Fill Sump Sensor(s). Model: x Mechanical Line Leak Detector. Model: LD 2000 ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: _VMI ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model - odel:Others Other (seci equipment t e and model in Section E on Page 2). t_1Other (specify equipment type and model in Section E on Page 2), Tank ID: Tank ID: ❑ 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: ❑ Piping Sump/ Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ 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), Dispenser ID: _1-2 Dispenser ID: _3-4 x Dispenser Containment Sensor(s). Model: _VR 208 x Dispenser Containment Sensor(s). Model: 208 ❑ Shear Valve(s). ❑ Shear Valve(s). _VR ❑ Dispenser Containment Floats and Chain(s), ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: _Satellite 1 Dispenser ID: _Satellite 4-5 x Dispenser Containment Sensor(s). Model: _VR 208 x Dispenser Containment Sensor(s). Model: 208 ❑ Shear Valve(s).❑ Shear Valve(s). _VR 11Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: _Satellite _2-3 Dispenser ID: _5 x Dispenser Containment Sensor(s). Model: _VR 208 x Dispenser Containment Sensor(s). Model: 208 ❑ Shear Valve(s). ❑ Shear Valve(s). _VR ❑ Dispenser Containment Floats and Chains ❑ Dispenser Containment Float(s) and Chain(s). tank and dispenser at the facility. C. Certification - I certify that the equipment identified in this document was inspectedlserviced in accordance with the manufacturers' guidelines. Attached to this Certification are 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 histgDf. report y Technician Name (print): Gabe Garcia Certification No.: B42919 Testing Company Name: _JP PetroleUm SerVICe Signature: License. No.: 811471 Phone No.:(_916�_372-5693 Testing company Address: 3065 Asante Lane, W. Sacto Ca 95691 Monitoring System Cert ification Page 1 of 4 1 Date of Testing/Servicing: _10-25-18 12107