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0 9 Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at httpalwww.swrcb.ca.gov.) MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, 77tle 23, Callfornia 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. Make/Model of Monitoring System: Veeder Root TLS 350 B. Inventory of Equipment Tested/Certified rr.arl.+ha n.,.,.,.. A. *a ti.. a+n in ilrmta cnarar;r a dnmant incnartadr1l 11 - 209-599-0149 Date of Testing/Servici ng: 1/27/2015 Tank ID: T1:SUPREME UNLEADED - PREMIUM Tank ID: TZ:REGULAR UNLEADED - REGULAR r In -Tank Gauging Probe. Modek mag r In -Tank Gauging Probe. Model: maq r Annular Space or Vault Sensor. Model: 409 r Annular space or Vault Sensor. Model: 409 F-1 Piping Sump / Trench Sensor(s). Model: 208 r Piping Sump / Trench Sensor(s). Model: 208 r Fill Sump Sensor(s). Model: 208 r Fill Sump Sensor(s). Model: 208 r Mechanical Line Leak Detector. Model: r Mechanicat Line Leak Detector. Model: r Electronic Line Leak Detector. Model: Veeder Root PLLD r Electronic tine Leak Detector, Model: Veeder Root PLLD r Tank Overfill / High -Level Sensor. Model: flapper r Tank Overfill / High -Level Sensor. Model: flapper I Other(specify equipment a and model in Section E on Pae 2). Other(specify equipment a and model in Section E on Pae 4. Tank ID: Tank ID: r In -Tank Gauging Probe, Model: in -Tank Gauging Probe. Model: r Annular Space or Vault Sensor. Model: 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: r Mechanical Line Leak Detector. Model: r Mechanical Line Leak Detector. Model: r-1 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: rl Other(specify equipment a and model in Section E on Pae 2). Other(specify equipment a and model in Section E on Pae 2). Dispenser 1/2 Dispenser 3/4 ID: ID: P, Dispenser Containment Sensor(s). Model; 208 r 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). Dispenser 5/6 Dispenser 7/8 ID: ID: r Dispenser Containment Sensor(s). Model: 208 r Dispenser Containment Sensor(s), Model: 20B 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 9/10 Dispenser 11/12 ID: ID: r Dispenser Containment Sensor(s). Model: 208 r 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 racaity contains more tanks or c spensers, copy tnis rorm. Insulae rnrormation ror every tanK ano oispenser ac me racmry. 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 thatapply): r System set- up r Alarm history report Technician Name (print); Jarrod Cooke Certification No.: B35255 License. No.: _ Signature: _ 743160 Class 'A' Z�� Testing Company Name: Tanknology Phone No.: (800) 800-4633 Testing Company Address: 11000 N. MoPac Expressway Suite 500 Date of Testing/Servicing: Monitoring System Certification Page 1 of 3 1/27/2015 12/07 RECEIV . El MAR 1 2015 ENVIRONMENTA! IJC'A`T'r ^.COA "r%Arkt