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Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.swrcb.cbtt` J 03 Z015 MONITORING SYSTEM CERTIFICATION UL II 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 v .r 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 Zip: 95215 Facility Contact Person: Contact Phone No.: - Make/Model of Monitoring System: Veeder Root TLS -350 Date of Testing/Servicing: 9/29/2015 B. Inventory of Equipment Tested/Certified f`I.e.•L Hsu �nn.r.n.ia►n r.nvm M iniliroln �naiF� on. i mm�nf i n cncrfc.i / ca n.:�crl Tank ID: TI : Diesel10K - Diesel Tank ® ID: T3 : EXFLUID - Diesel Exhaust Fluid We' In -Tank Gauging Probe. Model: mag In -Tank Gauging Probe. Model: mag W11 Annular Space or Vault Sensor. Model: 420 ❑ Annular Space or Vault Sensor. Model: r Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ 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: external alarm r Tank Overfill / High -Level Sensor. Model: M' Other (specify equipment and model in Section E on Pae 2). r Other(specify equipment a and model in Section E on Pae 2). Tank ID: T2: Diesel10K - Diesel Tank ID: In -Tank Gauging Probe. Model: n In -Tank Gauging Probe. Model: mag❑ Annular Space or Vault Sensor. Model: 420 ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: r Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: F Mechanical Line Leak Detector. Model: [ I Mechanical Line Leak Detector. Model: r Electronic Line Leak Detector. Model: r Electronic Line Leak Detector. Model: r Tank Overfill / High -Level Sensor. Model: -2) r Tank Overfill / High -Level Sensor. Model: Other (specifv equipment and model in Section E on Pae . other (specify equipment a and model in Section E on Pae 2). Dispenser 1 Dispenser ID: ID: (� Dispenser Containment Sensor(s). Model: [ Dispenser Containment Sensor(s). Model: r Shear Valve(s). ❑ Shear Valve(s). F,1_ Dispenser Containment Float(s) and Chain(s). r Dispenser Containment Float(s) and Chain(s). Dispenser 2 Dispenser ID: ID: r Dispenser Containment Sensor(s). Model: r Dispenser Containment Sensor(s). Model: FV Shear Valve(s). r Shear Valve(s). y] 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 tacnity contains more [anus or dispensers, copy this Corm. incivae mtormation tor every tanK ana aispenser at the racuity. 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 appal. r System set- up r Alarm history report Technician Name (print): Steve Willems Certification No.: 836743 Signature: �k XJLv+- License. No.: 743160 Class 'A' Testing Company Name: Tanknology Testing Company Address: 11000 N. MoPac Expressway Suite 500 Monitoring System Certification Phone No.: (800) 800-4633 Page i of 3 Date of Testing/Servicing: 9/29/2015 12/07 J