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Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.swrcb.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: CHEVRON 307709 Bldg. No.: Site Address: 10858 TRINITY PKWY City: STOCKTON Facility Contact Person: MANAGER (N-7462-1-10) Make/Model of Monitoring System: Veeder Root TLS -350 B. Inventory of Equipment Tested/Certified P1.....1. H..... :ter.. 1.---- F.. ;-Al—le -,M, nn..imm�nF in n�in.l /anr••irn•1• Zip: 95219 Contact Phone No.: 209-952-2213 Date of Testing/Servicing: 4/24/2013 Tank ID: T1 - UNLEADED Tank ID: T-2 - PREMIUM In -Tank Gauging Probe. Model: mag rvo' In -Tank Gauging Probe. Model: mag Annular Space or Vault Sensor. Model: 303 r%_0 Annular Space or Vault Sensor. Model: 303 Piping Sump / Trench Sensor(s). Model: 208/304 11-1 Piping Sump / Trench Sensor(s). Model: 208/304 r Fill Sump Sensor(s). Model: 208/304 rV_ Fill Sump Sensor(s). Model: 208/304 i Mechanical Line Leak Detector. Model: r Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Veeder Root PLLD [V_ Electronic Line Leak Detector. Model: Veeder Root PLLD Tank Overfill / High -Level Sensor. Model: external alarm r Tank Overfill / High -Level Sensor. Model: EXTERNAL ALARM Other(specify equipment a and model in Section E on Pae 2). F Other(specify equipment a and model in Section E on Pae 2). Tank ID: T-3 - Diesel Tank ID: [_ In -Tank Gauging Probe. Model: In -Tank Gauging Probe. Model: mag 11-0 Annular Space or Vault Sensor. Model: 303 r Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: 208/304 r Piping Sump / Trench Sensor(s). Model: r Fill Sump Sensor(s). Model: 208/304 r Fill Sump Sensor(s). Model: r Mechanical Line Leak Detector. Model: r Mechanical Line Leak Detector. Model: j� Electronic Line Leak Detector. Model: Veeder Root PLLD r Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: external alarm r Tank Overfill / High -Level Sensor. Model: Other(specify equipment a and model in Section E on Pae 2). Other(specify equipment a and model in Section E on Pae 2). Dispenser 1/2 Dispenser 3/4 ID: ID: rv— Dispenser Containment Sensor(s). Model: 208/304 Dispenser Containment Sensor(s). Model: 208/304 Shear Valve(s). r Shear Valve(s). j— Dispenser Containment Float(s) and Chain(s). r Dispenser Containment Float(s) and Chain(s). Dispenser 5/6 Dispenser 7/8 ID: ID: r Dispenser Containment Sensor(s). Model: 208/304 r Dispenser Containment Sensor(s). Model: 2 r Shear Valve(s). r Shear Valve(s). r Dispenser Containment Float(s) and Chain(s). r Dispenser Containment Float(s) and Chain(s). Dispenser 9/10 Dispenser 11/12 ID: ID: Dispenser Containment Sensor(s). Model: 208/304 r,—/ Dispenser Containment Sensor(s). Model: 208/304 P7 Shear Valve(s). Shear Valve(s). r Dispenser Containment Float(s) and Chain(s). r Dispenser Containment Float(s) and Chain(s). *It the tacility contains more tanKs or dispensers, copy tins Torm. >ncivae imormation Tor every tanK dna dispenser do We 1danI.y. 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): r System set- up P Alarm history report Technician Name (print): Jarrod Cooke Certification No.: B35255 Testing Company Name: Tanknology License. No. Signature:�� 743160 Class 'A' Phone No.: (800) 800-4633 Testing Company Address: 11000 N. MoPac Expressway Suite 500 Date of Testing/Servicing: 4/24/2013 Monitoring System Certification Page 1 of 4 12/07