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KIXEIVED • JUN 0 3 2016 Appendix VI ENVRDbfH IEHTA� (Copies of Monitoring System Certificafion form and UST Monitoring Plot Plan available at httD'//www&MR9i I2fasuyWW TH 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, Tide 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 forth must be provided to the tank system owner/operator. The owner/operator must submit a copy of this forth to the local agency regulating UST systems within 30 days of lest date. A. General Information Facility Name: GEMCO Bldg.No.: Site Address: 1022 FRONTAGE ROAD City: RIPON Zip: 98368 Facifify Contact Person:_JOHAL _ Contact Phone No.: 201 9 1 841.8180 Make/Model of Monitoring System: TLS Date of Testing/Servicing: 03 / 17 / 2016 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific ui ent ins tedlserviced: Tank ID: TANK 1 REG.UNL. Tank ID: TANK 2 PREMIUM • Mi-Tank Gauging Probe.. Model: MAG 1 I& In-Tank Gauging Probe_ Madel• YAG 1 ® Annular Space or Vault Sensor. Model: 420 ® Annular Space or Vault Sensor. Model: 420 I@ Piping Sump/Trench Semor(s). Model: 206 ® Piping Sump/Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: VMI LD2000 ® Mechanical Line Leak Detector. Model: VMI LD2000 u Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model ® Tank Overfill/High-Level Sensor. Model: OPW VALVE ® Tank Overfill/High-Level Sensor. Model: OPW VALVE ❑ Others ci equipment type and model in Section E on Pae 2. C Other(s22cify equipment and model in Section E on Page 2). TanklD: Tank1D: In-Tank Gauging Probe. Model In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: C Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Madel: ❑ Piping Sump/Trench Sensor(s). Model: u Fill Sump Sensoria). Model: u Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: — Mechanical Lime Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: E Electronic Line Leak Detector. Model: ❑ Tank Overfill i High-Level Sensor. Model: C Tank Overfill/High-Level Sensor. Model: v Others ci ui ment t and modat in Section E o!Pagal. a Others ci ui ment t e and model in Section E on Pa Dispenser ID: DISP. 1&2 3&4 Dispenser ID: DISP. 13114 ® Dispenser Containment Sensor(a). Model: 208 ® Dispenser Containment Sensoria). Model: 208 ® Shear Valve(s). ® Shear Valve(s). Li Dispenser Containment Floats and Chain(s). u Dispenser Containment Float(s) and Chain(s). Dispenser 10: DISP 8&6 7&6 Dispenser ID: ® Dispenser Containment Sensor(s). Model: 208 C Dispenser Containment Sensor(s). Model: ® Shear Vaive(s). :i Shear Vatve(s). Dis 2 enser Containment Floats and Chain(s). _ Dispenser Containment Float(s)and Chain(s). Dispenser ID: DISP 9&10 11&12 Dispenser ID: ® Dispenser Containment Sensor(s). Model: 208 - Dispenser Containment Semons). Model:_. ® Shear Valve(s). 7 Shear Valve(s). ^ Dispenser Containment Float s)and Chain s - Dispenser Containment Float(s)and Chaln(s). *if the facility contains more tanks or dispensers,copy this forth. 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 inforn 'on is correct and a Plot Plan showing the layout of monitoring equipment For any equipment capable of Eo'( 209 uch reports,I e also attached a copy of the report;(check all that apply): py-System set-up SAlarrn history reportTechnician Name(print): GREG KAISER Signature: Certification No.: A25983 License.No.: 859 Testing Company Name: KAISER COMMERICAL PETROLEUM PhoneE887-2639 Testing Company Address: P.O.BOX 1068 LINDEN CA 95236 Date of Testing/Servicing: 03 _L17 / 2016 Monitoring System Certification Page 1 of 4 12107 ] 2/21/07