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Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.swrcb.c Y.)l 2 2016 MONITORING SYSTEM CERTIFICATION k1 , !�yi► . 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 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: DP&DK INV.INC. Bldg. No.: Site Address: MARCH LANE SHELL1206 E. MARCH LANE City: STOCKTON Zip: 95210 Facility Contact Person: KARAM SINGH Contact Phone No.: 510-926-7834 Make/Model of Monitoring System: Veeder Root TLS-350 Date of Testing/Servicing: 5/4/2016 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment ins ected/serviced: Tank ID: 1-REGULAR Tank ID: 2-PREMIUM In-Tank Gauging Probe. Model: MAG P7 In-Tank Gauging Probe. Model: MAG r Annular Space or Vault Sensor. Model: 794380-407 P-7 Annular Space or Vault Sensor. Model: 7943801107 r Piping Sump/Trench Sensor(s). Model: 794380-208 rl—F Piping Sump/Trench Sensor(s). Model: 205 r Fill Sump Sensor(s). Model: r_. Fill Sump Sensor(s). Model: r Mechanical Line Leak Detector. Model: Vaporless LD-2000 r Mechanical Line Leak Detector. Model: Vaporless LD-2000 r Electronic Line Leak Detector. Model: r Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor.Model: EXT AUD/VIS rV_ Tank Overfill/High-Level Sensor.Model: EXT AUD/VIS Other(specify equipment t e and model in Section E on Pae 2)_ Other(specify equipment t e and model in Section E on Page 2). Tank ID: 3-Diesel Tank ID: PF In-Tank Gauging Probe. Model: MAG r In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 794380-407 r7 Annular Space or Vault Sensor. Model: P Piping Sump/Trench Sensor(s). Model: 205 r7 Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: r7 Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Vaporless LD-2000 Mechanical Line Leak Detector. Model: r Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor.Model: EXT AUD/VIS Tank Overfill/High-Level Sensor.Model: Other(specify equipment a and model in Section E on Pae 2). Other(specify equipment a and model in Section E on Pae 2). Dispenser 1/2 Dispenser 3/4 ID: ID: Dispenser Containment Sensor(s).Model: 794380-208 � Dispenser Containment Sensor(s).Model: 205 Shear Valve(s). r7o� Shear Valve(s). r Dispenser Containment Float(s)and Chain(s). r, Dispenser Containment Float(s)and Chain(s). Dispenser 5 Dispenser 6 ID: ID: P-1 Dispenser Containment Sensor(s).Model: 205 r%F Dispenser Containment Sensor(s).Model: 205 Shear Valve(s). r7o� Shear Valve(s). r Dispenser Containment Float(s)and Chain(s). r—, Dispenser Containment Float(s)and Chain(s). Dispenser 7/8 Dispenser g/10 ID: ID: Dispenser Containment Sensor(s).Model: 205 r Dispenser Containment Sensor(s).Model: 794380-208 r Shear Valve(s). �' Shear Valve(s). r Dispenser Containment Float(s)and Chain(s). r7 Dispenser Containment Float(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 a//that app/y):r System set- up rl!O.Alarm history report Technician Name(Print): Todd Inderbitzen Signature: Certification No.: 845335 License.No.: 743160 Class'A' Testing Company Name: Tanknology Phone No.: (800)800-4633 Testing Company Address: 11000 N.MoPac Expressway Suite 500 Date of Testing/Servicing: 5/4/2016 Monitoring System Certification Page 1 of 3 12/07