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'I his i s no+ a- Y�'10��1Un�� art Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at httpJlwww.waterboards.ca.aov.) MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the Stale 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 owner/operator. 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: Pershing Gas Bldg. No.: Site Address: 4445 N Pershing Gas City: Stockton 7ip:95207 Facility Contact Person: Gary Contact Phone No.:(408) 515.0000 Make/Model of Monitoring System: TLS 350 Date of Testing/Servicing: 3/29/2017_ B. Inventory of Equipment TestedlCertified Check thea pro riate boxes to indicate specific equipment ins cted/serviced: Tank ID: 87 -- Tank ID: 91 X In -Tank Gauging Probe. Model: VR -115 X In -Tank Gauging Probe. Madel: VRA 15 X Annular Space or Vault Sensor. Model: 420 X Annular Space or Vault Sensor. Model: 420 Piping Sump / Trench Sensor(s). Model: Piping Sump / Trench Sensor(s). Model Fill Sump Sensor(s)_ Madel: _ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model Mechanical Line Leak Detector. Model: -- X Electronic Line Leak Detector. Model: -PLLQ X Electronic Line Leak Detector. Model: PLLD Tank Overfill / High -Levet Sensor. Model: Tank Overfill i High -Level Sensor. Madel. Other(specify equipment a and model in Section E on Page.?). Other (specify equipment t and model in Section E on Page 2). Tank Ill _DIE Tank ID: X In -Tank Gauging Probe. Model: VR -115 In -Tank Gauging Probe. Model: X Annular Space or Vault Sensor. Model: 420 Annular Space or Vault Sensor. Madel: Piping Sump) Trench Sensor(s). Model: _. Piping Sump F Trench Sensor(s). Model: i Fill Sump Sensor(s). Model: Fill Sump Sensor(s)_ Model: Mechanical Line Leak Detector. Model: PLLD Mechanical Line Leak Detector. Model: X Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: I Tank Overfill 1 High -Level Sensor. Model. Tank Overfill / High -Level Sensor. Model: I . Other �spcciN equipment type and model in Section E on Page 2). Other (specify equipment t pe and model in Section E on Pa e .2L Dispenser ID: 1/2 Dispenser ID: 3!4 F Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: O Shear Valve($). (OPW) Shear Valve(s). X Dispenser Containment Ficial s and Chain�sj. ntainment Float(s) and Chains . Dispenser ID: 518 Dispenser ID: Dispenser Containment Sensor(s). Model: _ i Dispenser Containment Sensors) Model: O Shear Valve(s), (DPW) i Shear Valve(s). X Disp2nser Containment Floa s and Chain(s). IDispenser Containment Floats and Chains . Dispenser ID: Dispenser ID: Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: ShearValve(s). (OPW) ShearVatve(s) (� Dispenser Containment Floats and Chains Dispenser Containment Float(s) and Chains . 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 inspectecilserviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturer checklists) necessary to verify that this Information Is correct and a Plot Pian showing the layout of monitoring equipment. For any equ ment capable of generating such reports, I have also attached a copy of the report; (check all that apply): System set-up Alar his r Technician Name (print): Fred Babel _Signature: Certification No.: VR - B357231 ICCOOD25547_— License. 1001331 A HAZ Testing Company Name- ELITE IV CONTRACTORS Phone No.:L209_)_461-6337 Testing Company Address: 2535 Wigwam Dr Stockton Ca 95205 Date of Testing/Servicing: 3i29f2017 Monitoring System Certification Page 1 of 4 RECEIVED 12107 JAN 2 4 2018 ENVIRONMENTAL HEALTH 2/21/07 DEPARTMENT