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Appendix Vl (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http:/lunvw.waterboards.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 76, Division 3, Title 23, Califofnia 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 ownerlopefator. 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: Modara Chevron Bldg_ No.*60 Site Address: 10879 N. Hwy 99 City: Stockton Zip: 95212 Facility Contact Person Billal Contact Phone No (209)931-6154 MakelModel of Monitoring System: Veeder-Root TLS -3508 Date of TestinglServiang: 6/24111 Inventory of Equipment Tested/Certified Check the appropiriate boxes to indicate specific equipment ins serviced: Tank ID: T1 — 91 Super Tank ID: T3 -- 87 Regular ® In -Tank Gauging Probe. Model: 0 In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor Model: 79439OD-42o (Split Tank) Annular Space or Vault Sensor. Model: 7943900-420 ® Piping Sump/ Trench Sensor(s), Model: 794380-208 Piping Sump/ Trench Sensor(s). Model: 794380-208 ❑ Fill Sump Sensogs). Model: ❑ Fill Sump Sensor(s). Model: 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 f High -Level Sensor. Model ❑ Tank Overfill / High -Level Sensor Model: Other (specify ui ment tyee and model in Section E on Page 21. ❑ Other (specify ui ment type and model in Section E on Page 2). Tank ID: T2 — 89 Plus Tank ID: T4 - Diesel ® in -Tank Gauging Probe. Model; ❑ In -Tank Gauging Probe. Model- ® Annular Space or Vault Sensor. Model: 794390D-420 (Split Tank) ❑ Annular Space or Vault Sensor. Model: 7943900420 (Split Tank) ® Piping Sump! Trench Sensors) Model: 794380-208 ❑ Piping Sump I Trench Sensor(s). Model: 794380-206 ❑ 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 Line Leak Detector. Model: El Tank Overfill! High -Level Sensor. Model: ❑ Tank Overfill! High -Level Sensor, Model: ❑ Other (sReciU equipment a and model in Sectionon Page 2). ❑ Other (specify ui ment type and mode; in Section E on Page 2). Dispenser ID: 1-2 ,E Dispenser ID: 3-4 ❑ Dispenser Containment Sensor(s). Model- ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ® Shear Valve(s). ® Dispenser Containment Floats) and Chain(s). N Dispenser Containment Floa s and Chain(s). Dispenser ID: 5-6 Dispenser ID: 7-8 ❑ Dispenser Containment Sensor(s). Model ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s), Shear Velve(s). ® Dispenser Containment Float(s) and Chain(s). ® Dispenser Containment Floa s and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model C1 Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chains ❑ Dis enser Containment Floa s and Chain(s). 'If the facility contains mare 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 inspectediserviced in accordance with the manufacturers' guidelines. Attached to this Certification is Information (e.g_ manufacturers' checkilsts) 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): us ems I ® 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 Pines, Ca 995726 Date of Testing/Servicing: 6124!11 Monitoring System Certification Page 1 of 4 12107 2%21107