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QREGEV �.D Appendix VI SEP 2 6 2016 (Copies of Monitoring system Certification form and UST Monitoring Plot Plan available at http://www.swrcb.ca.gov.) MONITORING SYSTEM CERTIFICATIOI*-NVIRONMENTAL HEALTH For Use By Ali Jurisdictions Within the State of California DEPARTMENT 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: 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 rhnri, +ho hnvna to indi.... .... M.., inc +nd /- A -Al - Zip: 95215 Date of Testing/Servicing: 9/16/2016 Tank ID: TI : Diesel10K - Diesel Tank ID: T2 : Diesel10K - Diesel r In -Tank Gauging Probe. Model: 846390-107 r7o In -Tank Gauging Probe. Model: 846390-107 Annular Space or Vault Sensor. Model: 794390-420 R Annular Space or Vault Sensor. Model: 794390-420 Piping Sump / Trench Sensor(s). Model: r Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: r Fill Sump Sensor(s). Model: j Mechanical Line Leak Detector. Model: r Mechanical Line Leak Detector. Model: r Electronic Line Leak Detector. Model: r Electronic Line Leak Detector. Model: ❑ 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). r Other (Wecify equipment a and model in Section E on Pae 2). Tank ID: T3 : EXFLUID - Diesel Exhaust Fluid Tank ID: r In -Tank Gauging Probe. Model: 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: I— Electronic Line Leak Detector. Model: r Electronic Line Leak Detector. Model: F_ Tank Overfill / High -Level Sensor. Model: (— Tank Overfill / High -Level Sensor. Model: Other(specify equipment a and model in Section E on Page 2). Other(specify equipment a and model in Section E on Pae 2). Dispenser 1 Dispenser 2 ID: ID: r Dispenser Containment Sensor(s). Model: F_ Dispenser Containment Sensor(s). Model: 570 Shear Valve(s). r Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Pr Dispenser Containment Float(s) and Chain(s). Dispenser lsat Dispenser 2sat ID: ID: ❑ Dispenser Containment Sensor(s). Model: r Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). r Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). r Dispenser Containment Float(s) and Chain(s). Dispenser Dispenser ID: ID: Dispenser Containment Sensor(s). Model: r Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). r Shear Valve(s). r Dispenser Containment Float(s) and Chain(s). r Dispenser Containment Float(s) and Chain(s). *If the facility contains more tanks or dispensers, copy this form. lncluae Information ror every LanK ana aispenser at the racnity. 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): F. System set- up P Alarm history report Technician Name (print): Jeffrey Crisostomo Certification No.: 842876 Testing Company Name: Tanknology _ Signature: License. No.: 743160 Class'A' Phone No.: (800) 800-4633 Testing Company Address: 11000 N. MoPac Expressway Suite 500 Date of Testing/Servicing: 9/16/2016 Monitoring System Certification Page 1 of 3 12/07