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• • RECEIVED Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http11www.swrOb1 aVB a 1 MONITORING SYSTEM CERTIFICATION ENVIRONMENTAL For Use By All Jurisdictions Within the State of California l J C 4 r rU e)CD4 0TilA Ciii li" 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 he 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 210997 (N-4693) Bldg. No.: Site Address: 1442A COLONY DR. City: RIPON Zip: 95366 Facility Contact Person: PATTY Contact Phone No. Make/Model of Monitoring System: Veeder Root TLS 350 B. Inventory of Equipment Tested/Certified r_ ,..,sa,� i. . 209-599-0149 Date of Testing/Servicing: 1/27/2015 Tank ID: T1:SUPREME UNLEADED - PREMIUM Tank ID: T2:REGULAR UNLEADED - REGULAR r In -Tank Gauging Probe. Model: mag P In -Tank Gauging Probe. Model: mag r Annular Space or Vault Sensor. Model: 409 P Annular Space or Vault Sensor. Model: 409 r Piping Sump / Trench Sensor(s). Model: 208 IV Piping Sump / Trench Sensor(s), Model: 208 r Fill Sump Sensor(s). Model: 206 r Fill Sump 5ensor(s). Model: 208 r Mechanical Line Leak Detector. Model: r Mechanical Line Leak Detector. Model: r Electronic Line Leak Detector. Model: Veeder Root PLLD r Electronic Line Leak Detector. Model: Veeder Root PLLD P Tank Overfill / High -Level Sensor. Model: flapper {v Tank Overfill / High -Level Sensor. Model: flapper Other (specifX equipment a and model in Section E on PageTT_ , 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: I— 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). Other(specify equipment a and model in Section E on Page 2). Dispenser 1/2 Dispenser 314 ID: ID: r Dispenser Containment Sensor(s). Model: 208 ;w Dispenser Containment Sensor(s). Model: 208 W Shear Valve(s). P Shear Valve(s). r Dispenser Containment Float(s) and Chain(s). r Dispenser Containment Float(s) and Chain(s). Dispenser 5/6 Dispenser 71S ID: ID: Dispenser Containment Sensor(s). Model: 208 r Dispenser Containment Sensor(s). Model: 208 P Shear Valve(s). r Shear Valve(s). r Dispenser Containment Float(s) and Chain(s). r Dispenser Containment Floats and Chain(s). Dispenser 9/10 Dispenser 11/12 ID: ID: r Dispenser Containment Sensor(s). Model: 208 Dispenser Containment Sensor(s). Model: 208 170 Shear Valve(s). r Shear Valve(s). r Dispenser Containment Float(s) and Chain(s). r Dispenser Containment Floats and Chain(s). -it the raciiity contains more tanrs or alspen5ers, Copy mis iomi, a�ruuue uuumiauvu wa "v Iy WI , .,,u ugr1- USG 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) Pr System set- up rAlarm history report Technician Name (print): Jarrod Cooke Certification No.: 835255 Testing Company Name: Tanknology Signature: License. No.: 743160 Class'A' Phone No.: (800) 8OG-4633 Date of Testing/Servicing: 1/27/2015 Testing Company Address: 11000 N. MoPac Expressway Suite 500 Monitoring System Certification Page 1 of 3 12/07