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1 � • • �AECEIVEU Appendix VI j 1 2015 (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.swrcbMv Ov MONITORING SYSTEM CERTIFICATION :NVIRONMENTAl, 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�'e ,T��r�r r 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: MARCH LANE SHELL Bldg.No.: Site Address: 1206 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 TLS350 Date of Testing/Servicing: 5/6/2015 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment Inspected/serviced: Tank ID: 1-REGULAR Tank ID: 2-PREMIUM r',In-Tank Gauging Probe. Model; MAG 8473 r In-Tank Gauging Probe. Model: MAG 8473 r Annular Space or Vault Sensor. Model: r Annular Space or Vault Sensor. Model: W Piping Sump/Trench Sensor(s). Model: 794380-208 ry Piping Sump/Trench Sensor(s). Model: 794390-205 r Fill Sump Sensor(s). Model: r Fill Sump Sensor(s). Model: r'Mechanical Line Leak Detector. Model: Vaporless LD-2000 Mechanical Line Leak Detector. Model: Vaporless LD-2000 Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: r',Tank Overfill/High-Level Sensor,Model: EXTERNAL AUDIBLE (7 Tank Overfill/High-Level Sensor.Model: EXTERNAL AUDIBLE Other(specify equipment a and model in Section E on Page 2). (— Other s eci a ui ment type and model in Section E on Pae 2). Tank ID: 3-Diesel Tank ID: 17 In-Tank Gauging Probe. Model: MAG 8473 r In-Tank Gauging Probe. Model: r Annular Space or Vault Sensor. Model: r Annular Space or Vault Sensor. Model: r Piping Sump/Trench Sensor(s). Model: 794390-205 r Piping Sump/Trench Sensor(s). Model: r Fill Sump Sensor(s). Model: r Fill Sump Sensor(s). Model: Wo Mechanical Line Leak Detector. Model: Vaporless LD-2000 r Mechanical Line Leak Detector. Model: r Electronic Line Leak Detector. Model: r Electronic Line Leak Detector. Model: r Tank Overfill/High-Level Sensor.Model: EXTERNAL AUDIBLE r Tank Overfill/High-Level Sensor.Model: r Other(specify equipment a and model in Section E on Pae 2). Other(specify equipment a and model in Section E on Page 2). Dispenser 1/2 Dispenser 3/4 ID: ID: Dispenser Containment Sensor(s).Model: 794380-208 fV- Dispenser Containment Sensor(s).Model: 794390-205 r Shear Valve(s). rV Shear Valve(s). r Dispenser Containment Float(s)and Chain(s). r Dispenser containment Floats and Chain(s). Dispenser 5 Dispenser 6 ID: ID: (70 Dispenser Containment Sensor(s).Model: 794390-205 r'Dispenser Containment Sensor(s).Model: 794390-205 R Shear Valve(s). r Shear Valve(s). r Dispenser Containment Floats and Chain(s). r Dispenser Containment Floats and Chain(s). Dispenser 7/8 Dispenser 9/10 ID: ID: r Dispenser Containment Sensor(s),Model: 794390-205 rV Dispenser Containment Sensor(s).Model: 794380-208 P Shear Valve(s). P Shear Valve(s). r Dispenser Containment Floats and Chain(s). r 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 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 all that apply):r System set- up P,Alarm history report Technician Name(print): Gilbert Garcia Signature: Certification No.: 842816 License.No.: 743160 Class'A' Testing Company Name: Tanknology Phone No.: (B00)800-4633 Testing Company Address: 11000 N.MoPac Expressway Suite 500 Date of Testing/Servicing: 5/6/2015 Monitoring System Certification Paye 1 of 3 12/07