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Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.waterboards.ca.go_v.) 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: FAST AND FASY Bldg. No.: Site Address: 10878 N. HM 99 Facility Contact Person: MIKEALE City: STOCTON CA, Zip: 95212 RECEIVED Contact Phone No.: Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 4/21/2014 MAY 0 6 2014 B. Inventory of Equipment Tested/Certified Chpck the annrnnrintp hnYps fin inriirntn c iflr anninmant inenartnrncnr A. A - Tank ID: 1 SUPREME Tank ID: UNLEADED ENRONMENTA X In -Tank Gauging Probe. Model VR MAG PROB X In -Tank Gauging Probe. Model: VR MAG PRERMli /SER{ X Annular Space or Vault Sensor. Model: VR 420 X Annular Space or Vault Sensor. Model: VR 420 X Piping Sump 1 Trench Sensor(s). Model: VR 208 X Piping Sump 1 Trench Sensor(s). Model: VR 208 Fill Sump Sensor(s). Model: ! Fill Sump Sensor(s). Model: X Mechanical Line Leak Detector, Model RED JACKET FXIV X Mechanical Line Leak Detector, Model: RED JACKET FXIV -I Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: I Tank Overfill l High -Level Sensor. Model: Tank Overfill 1 High -Level Sensor. Model: r1 Other (specify a ui ment a and model in Section E on Page 2). Other_(aE2ci equipment t e and model in Section E on Page 2). Tank ID:2 PLUS Tank ID: DIESEL X In -Tank Gauging Probe. Model: VR MAG PROB X In -Tank Gauging Probe. Model: VR MAG PROB X Annular Space or Vault Sensor. Model: VR 420 X Annular Space or Vault Sensor. Model: VR 420 X Piping Sump 1 Trench Sensor(s). Model: VR 208 X Piping Sump / Trench Sensor(s). Model: VR 208 Fill Sump Sensor(s). Model: ! Fill Sump Sensor(s). Model: X Mechanical Line Leak Detector. Model: VMI LD 2000 X Mechanical Line Leak Detector. Model: RED JACKET FXIV Electronic Line Leak Detector. Model: 7 Electronic Line Leak Detector, Model: Tank Overfill 1 High -Level Sensor. Model: I Tank Overfill 1 High -Level Sensor. Model: Other (specify equipment t e and model in Section E on Page 2). 17 Other (specify equipment a and model in Section E on Page 2). Dispenser ID: 112 Dispenser ID: 718 Dispenser Containment Sensor(s). Model: 7 Dispenser Containment Sensor(s). Model: Shear Valve(s). I Shear Valve(s). X Dispenser Containment Floats and Chain(s). BROVO X Dispenser Containment Floats and Chain(s). BROVO Dispenser ID: 314 Dispenser ID: 9110 Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: _ Shear Valve(s). _ Shear Valve(s). X Dispenser Containment Floats and Chain(s). BROVO Dispenser Containment Floats and Chain(s). Dispenser ID: 516 Dispenser ID: Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s), Model: Shear Valve(s). Shear Valve(s). X Dispenser Containment Floats and Chains BROVO - Dispenser Containment Floats and Chain(s). n ure raciiny comains more tanKs or aispensers, copy mis tome. inauae mrormauon for every tanK and dispenser at the tacmty. 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. manufactur checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any e ient capable of generating such reports, I have also attached a copy of the report; (check all that apply): System set-up Al rm story report Technician Name (print): JASON HAASE Signat e: Certification No.: B40970 License. No.. 10985 Testing Company Name. MID VALLEY CONSULTING Phone No.:(530) 49-9892 Testing Company Address: 1097 BRONCO DRIVE, PLUMAS LAKE, CA 95961 Date of TestinglServicing: 4121/2014 Monitoring System Certification Page 1 of 4 12107 1 2/21/07 . HEALTH ICES