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Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at httpJlwvvw.sWfcb.ca.gov.) MONITORING SYSTEM CERTIFICATION For Use ay 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 210997 (N-4693) Bldg. No.: Site Address: 1442A COLONY DR. City: RIPON Zip: 95366 Facility Contact Person: PATTY Contact Phone No.: 599-0149 Make/ Model of Monitoring System: Veeder Root TLS 350 Date of Testing/Servicing: 2/7/2013 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates ecitic equipment ms ectea serurcea: Tank ID: T1:SUPREME UNLEADED - PREMIUM Tank ID: T2:REGULAR UNLEADED - REGULAR r In -Tank Gauging Probe. Model: mag r In -Tank Gauging Probe. Model: mag Annular Space or Vault Sensor. Model: 409 r Annular Space or Vault Sensor. Model: 409 ry Piping Sump / Trench Sensor(s). Model 208 W Piping Sump / Trench Sensor(s). Model: 208 Fill Sump Sensor(s). Model: 208 r Fill Sump Sensor(s). Model: 208 r— Mechanical Line Leak Detector. Model: r— Mechanical Line Leak Detector. Model: R Electronic Line Leak Detector. Model: Veeder Root PLLD sJ Electronic Line Leak Detector. Model: Veeder Root PLLD Tank Overfill / High -Level Sensor. Model: flapper 170 Tank Overfill / High -Level Sensor. Model: Flapper r— Other (sEecify equipment a and model in Section E on Pa e 2 . r Other(specify equipment a and model in Section E on Pacie 2). Tank ID: Tank ID: I— In -Tank Gauging Probe. Model: [— In -Tank Gauging Probe. Model: • Annular Space or Vault Sensor. Model: r Annular Space or Vault Sensor. Model: • Piping Sump / Trench Sensor(s). Model r Piping Sump / Trench Sensor(s). Model: Fill Sump Sensor(s). Model: r Fill Sump Sensor(s). Model: r Mechanical Line Leak Detector. Model: r Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: r Electronic Line Leak Detector. Model: r Tank Overfill / High -Level Sensor. Model: Tank Overfill / High -Level Sensor. Model. Other(specify equipment a and model in Section E on Pae 2). r Other(specify equipment a and model in Section E on Pace 2). Dispenser 1/2 Dispenser 3/4 ID: ID: 170 Dispenser Containment Senser(s). Model: 208 r Dispenser Containment Sensor(s), Model: 208 W Shear Valve(s). W Shear Valve(s). I— 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 W/ Dispenser containment Sensor(s). Model: 208 r7 Shear Valve(s). Shear Valve(s). r Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser 9/10 Dispenser 11/12 ID: ID: r Dispenser Containment Sensor(s). Model: 208 [70 Dispenser Containment Sensor(s). Model: 208 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 ranKs or PlspenserS, Wpy uua iunn. ulLduuc — -1 Y .u..u -u u 'F ...... v+ ••r• C. Certification - I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certiflcation 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): V System set- up P7 Alarm history report Technician Name (print): Jarrod Cooke Certification No.: 835255 Testing Company Name: Tanknology Testing Company Address: 11000 N. MoPac Expressway Suite 500 License. No.: Signature: 743160 Class'A' Phone No.: (800) 8004633 Monitoring System Certification Page 1 of 3 Date of Testing/Servicing: 2/7/2013 12/07