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Appendix VI �,/ ROMPED(Copies of Monitoring System Certification form and UST Monitoring Plot Plan available athttp-//www.swrb.ca.po MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Fp��Rp�� 7T Authority Cited:Chapter 6.7,Health and Safety Code,Chapter 16,Division 3, Title 23, AIR Mi'ons This form must be used to document testing and servicing of monitoring equipment. A separate certificationpYoEtr report must be prepared for each monitoring system control by the technician who performs the work. A copy of this form must be provided to the tagJc 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: Estes Trucking Bldg.No.: Site Address: 7611 S.Airport Way City: Stockton Zip 95206 Facility Contact Person: Mark Hancock and Jim Bunck Contact Phone No.: 714.893.6140 Make/Model of Monitoring System: Veeder-Root TLS 350 Date of Testing/Servicing: May 12,2009 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific a ui ment inspected/serviced: Tank ID: #I DIESEL Tank ID: In-Tank Gauging Probe. Model:Mag Probe O In-Tank Gauging Probe. Model: (X)Annular Space or Vault Sensor. Model: VR 302 O Annular Space or Vault Sensor. Model: (X)Piping Sump/Trench Sensot{s). Model: VR903. ?A O Piping Sump/Trench Sensor(s). Model: O Fill Sump Sensor(s). Model: O Fill Sump Sensor(s). Model: ( )Mechanical Line Leak Detector. Model: O Mechanical Line Leak Detector. Model: O Electronic Line Leak Detector. Model: O Electronic Line Leak Detector. Model: O Tank Overfill/High-Level Sensor. Model: O Tank Overfill/High-Level Sensor. Model: O Other(specify equipment a and model in Section E on Page 2). O Other(specify equipment type and model in Section E on Page 2). Tank ID: #2 Tank ID: ( )In-Tank Gauging Probe. Model: O In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: O Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: O Piping Sump/Trench Sensor(s). Model: O Fill Sump Sensor(s). Model _ O Fill Sump Sensor(s). Model: O Mechanical Line Leak Detector. Model: O Mechanical Line Leak Detector. Model: O Electronic Line Leak Detector. Model: O Electronic Line Leak Detector. Model: O Tank Overfill/High-Level Sensor. Model: O Tank Overfill/High-Level Sensor. Model: O Other(specify equipment type and model in Section E on Page 2). O Other(specify equipment a and model in Section E on Pae 2). Dispenser ID: Dispenser ID: O Dispenser Containment Sensor(s). Model: O Dispenser Containment Sensor(s). Model: Shear Valve(s). O Shear Valve(s). ( )Dispenser Containment Float(s)and Chain(s). O Dis enser Containment Floats and Chains . Dispenser ID: Dispenser ID: Dispenser Containment Sensor(s). Model: O Dispenser Containment Sensor(s). Model: Shear Valve(s). O Shear Valve(s). ©Dispenser Containment Floats and Chains).Bravo O Dispenser Containment Floats)and Chain(s). Dispenser ID: Dispenser ID: O Dispenser Containment Sensor(s). Model: __ O Dispenser Containment Sensor(s). Model: Shear Valve(s). O Shear Valve(s). ODis enser Containment Floats and Chain(s). O Dispenser Containment Float(s)and Chain(s). -If the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility. 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 retort;(check all that apply): ( )System set-up ( )Alarm history report Technician Name(print): Eric Molgaard Signature: Eric Atioaard Certification No.: ICC Tech 525020OUT V/R A27995 License No.: 309105 Testing Company Name:STOCKTON SERVICE STATION EQUIPMENT CO.INC. Phone No 209-464-8333 Testing Company Address: 808N.Union Street,Stockton,CA 952054152 Date of Testing/Servicing: May 12,2009 Monitoring System Certification Page I of 3 12/07