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Appendix VI O C T 18 2017 (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.swrcb.ca.gov.) MONITORING SYSTEM CERTIFICATION ENVIRONMENTAL HEALTH For Use By All Jurisdictions Within the State of California � A Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, Californ'iW&PdfT"'ENT 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: CA -124 Bldg. No.: Site Address: 3663 Peterson Road City: Stockton Facility Contact Person: Contact Phone No.: Make/Model of Monitoring System: Veeder Root TLS -350 B. Inventory of Equipment Tested/Certified rhnrL the h.- to indirn}o cnnrifr a .in nt incnur+u.I /euwirorl• Zip: 95215 Date of Testing/Servicing: 10/12/2017 Tank ID: T1 : Diesel10K - Diesel Tank ID: T2 : Diesel 10K - Diesel P In -Tank Gauging Probe. Model: mag P In -Tank Gauging Probe. Model: mag P Annular Space or Vault Sensor. Model: 794390-420 P Annular Space or Vault Sensor. Model: 794390-420 F Piping Sump / Trench Sensor(s). Model: r Piping Sump / Trench Sensor(s). Model: r Fill Sump Sensor(s). Model: r Fill Sump Sensor(s). Model: r Mechanical Line Leak Detector. Model: r Mechanical Line Leak Detector. Model: r Electronic Line Leak Detector. Model: r Electronic Line Leak Detector. Model: r Tank Overfill / High -Level Sensor. Model: r Tank Overfill / High -Level Sensor. Model: 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: Tank ID: r In -Tank Gauging Probe. Model: r In -Tank Gauging Probe. Model: r Annular Space or Vault Sensor. Model: r Annular Space or Vault Sensor. Model: r Piping Sump / Trench Sensor(s). Model: r Piping Sump / Trench Sensor(s). Model: r Fill Sump Sensor(s). Model: r Fill Sump Sensor(s). Model: F Mechanical Line Leak Detector. Model: r Mechanical Line Leak Detector. Model: r Electronic Line Leak Detector. Model: r Electronic Line Leak Detector. Model: F Tank Overfill / High -Level Sensor. Model: r Tank Overfill / High -Level Sensor. Model: Other (soecifv equipment a and model in Section E on Page 2). Other(specify equipment a and model in Section E on Page 2 . Dispenser Dispenser ID: ID: r Dispenser Containment Sensor(s). Model: r Dispenser Containment Sensor(s). Model: 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 Dispenser ID: ID: r Dispenser Containment Sensor(s). Model: r Dispenser Containment Sensor(s). Model: 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 Dispenser ID: ID: r Dispenser Containment Sensor(s). Model: r Dispenser Containment Sensor(s). Model: r Shear Valve(s). r Shear Valve(s). r Dispenser Containment Float(s) and Chain(s). r Dispenser Containment Float(s) and Chain(s). -it the tacmty contains more tanKs or aispensers, copy tins Corm. incwae inTormarion Tor every ranK ano dispenser at me Tacu¢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): P System set- up P Alarm history report Technician Name (print): Jarrod Cooke Certification No.: B35255 Testing Company Name: Tanknology Testing Company Address: 11000 N. MoPac Expressway Suite 500 Monitoring System Certification License. No. Signature:�� 743160 Class'A' Phone No.: (800) 800-4633 Page 1 of 3 Date of Testing/Servicing: 10/12/2017 12/07