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0 0 Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.waterboards.ca. o fl MONITORING SYSTEM CERTIFICATION For Use By AP 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 he 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 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 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 -356R Date of Testing/Servicing' 1/27112 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspectedlserviced: Tank ID: T1 -- 91 Super Tank ID: T3 — 67 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: 79439OD-420 • Piping Sump 1 Trench Sensogs). Model: 794380-208 Piping Sump/ Trench Sensogs). Model: 794380-208 ❑ FII Sump Sensor(s)_ Model: ❑ Fill Sump Sensor(s). Model N Mechanical Line Leak Detector. Model: Red Jacket ❑ 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 ® Tank Overfill 1 High -Level Sensor Model: Drop Tube Flapper Valve ❑ Other(specify equipment t e and model in Section E on Page 2). ❑ Other(specify e ui ment type and model in SectionE on Page 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 7943900-420 (Split Tank) ❑ Annular Space or Vault Sensor. Model: 7943900--420 (Split Tank) ® Piping Sump I Trench Sensor(s). Model: 794380-208 ❑ Piping Sump/ Trench Sensor(s). Model: 794380-208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s), Model: ® Mechanical Line Leak Detector. Model: VMI ® Mechanical Line Leak Detector. Model: Red Jacket ❑ Electronic Line Leak Detector Model: ❑ Electronic lane Leak Detector_ Model: M Tank Overfill I High -Level Sensor. Model: Drop Tube Flapper Valve ® Tank Overfill I High -Level Sensor. Model Di Tube Flapper Valve ❑ Other(specify a ui mept type and model in Section E on Page 2 ❑ others ecify equipment a and model in Section E on Pa e 2 . Dispenser ID: 1-2 Dispenser ID. 3-A ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s)- Model: ® Shear Valve(s). Shear Valve(s). ® Dispenser Containment Float(s) and Chain(s). Dispenser Containment Floats and Chain{s Dispenser ID: 5-6 Dispenser ID: 7-8 ❑ Dispenser Containment Sensor(s). Model ❑ Dispenser containment Sensor(s). Modet ® Shear Valve(s). Shear Valve(s). l4 Dispenser Containment Float(sj and Chain(s). ❑ Dispenser Containment Floats and Chain(s) Dispenser ID: Dispenser 10: ❑ Dispenser Containment Sensor(s). Model ❑ Dispenser Containment Sensor(s). Model [] Shear Valve(s). ❑ Shear Valve(s) ❑ Dispenser Containment Floats and Chains ❑ Dispenser containment Floats 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 inspectedlserviced 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); ,System p 23 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 Pollock Panes, Ca 995726 Cate of TestinglServicing: 1127112 Monitoring System GertificAtion Page 1 of 4 12M7 2121107