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0 0 Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Pian available at http:llwww.walerboards.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, 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 ownerloperator. The ownerloperator 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: Morada Chevron Bldg. No.:#60 Site Address: 10879 N. Hwy 99 City: Stockton Zip: 95212 Facility Contact Person: Billal Contact Phone No.: (209)931.6154 Make/Model of Monitoring System: Veeder-Root TLS -3508 Date of Testing/Servicing: 9113112 Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment ins1 oected/serviced: Tank ID: T1 -- 91 Super Tank ID: T3 — 87 Regular ® In -Tank Gauging Probe, Model: 846390-107 ® In -Tank Gauging Probe. Model: 846390-107 ® Annular Space or Vault Sensor. Model: 79439OD-420 (Split Tank) Annular Space or Vault Sensor ModeL 79439013-420 Piping Sump l Trench Sensogs). Model: 794380-206 Piping Sump l Trench Sensor(s). Model: 794380-208 ❑ Fill Sump Sensogs). Model: ❑ Fill Sump Sensor(s). ModeL M Mechanical Line Leak Detector. Model: Red Jacket 0 Mechanical Line Leak Detector. Model: Red Jacket ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill I High -Level Sensor. Model: Drop Tube Flapper Valve R Tank Overfill I High -Level Sensor. Model: Drop Tube Flapper Valve ❑ Other(specify equipment t e and model in Section E on Page 2). © Others eci a quip ment ile and model in Section E on Pa2e 2), Tank ID: T2 — 89 Plus Tank ID: T4 - Diesel In -Tank Gauging Probe. Model: 846390-107 ❑ In -Tank Gauging Probe. Model: 846390-107 Annular Space or Vault Sensor. Model: 79439OD-420 (Split Tank) ❑ Annular Space or Vault Sensor. Model: 79439OD•420 (Split Tank) Piping Sump/ Trench Sensor(s). Model, 794380-208 ❑ Piping Sump 1 Trench Sensor(s), Model: 794380-208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensogs). Model: lZ Mechanical Line Leak Detector, Model: VMI M Mechanical Line Leak Detector. Model: fled Jacket ❑ Etectronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Mode$: M Tank Overfill I High -Level Sensor. Model: Drop Tube Flapper Valve ® Tank Overfill I High -Level Sensor. Model: Drop Tube Flapper Valve ❑ Other(specify equipment a and model in Section E on Page 2), ❑ Other(specify equipment t e and model in Section E on Pa e 2). Dispenser ID: 1-2 Dispenser ID: 3-4 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ® Shear Valve(s). ® Dispenser Containment Float(s) and Chain(s). 0 Dispenser Containment Ftoat s and Chain(s). Dispenser ID: 5-6 Dispenser ID: 7-8 ❑ Dispenser Containment Sensor(s). Model: L] Dispenser Containment Sensor(s)- Model: ® Shear Valve(s). ® Shear Valve(s). 0 Dispenser Containment Floats and Chains . ® Dis enser Containment Floats and Chain(s). Dispensertp: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chains ❑ Dispenser Containment Floa 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 report; (check all that apply): E Syste et -up 2 Alarm history report Technician Name (print): Ronnie Lewis Signature: Certification No.: A26833 License. No.: 949066 Testing Company Name: Nucleus Pump Services Phone No.:(530) 644-8465 Testing Company Address: 4960 Pine Tree Ln Poilock Pines, Ca 995726 Date of Testing/Servicing- 911all 2 Monitoring System Certification Page 1 of 4 12107 2121107