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Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at httD,/Avww 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 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: March&Bianchi Chevron Bldg.No.: Site Address: 1916 March Lane City: Stockton Zip: 95207 Facility Contact Person: Giljeet Contact Phone No.: 209-954-0945 Make/Model of Monitoring System:VEEDER ROOT TLS 350 Date of TeslinglServicing: 08/24/2012 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment ins ctedlserviced: Tank ID: 1 UNLEADED Tank ID: DIESEL X In-Tank Gauging Probe. Model: VR MAG PROBE 1 X In-Tank Gauging Probe. Model:VR MAG PROS 1 X Annular Space or Vault Sensor. Model: VR 420 X Annular Space or Vault Sensor. Model:VR 420 X Piping Sump/Trench Sensor(s). Model: VR 208 X Piping Sump/Trench Sensor(s). Model:VR 208 X Fill Sump Sensor(s). Model: VR 208 X Fill Sump Sensor(s). Model:VR 208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: X Electronic Line Leak Detector. Model: VR ELLD X Electronic Line Leak Detector. Model: VR ELLD ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: X Other(specify equipment type and model in Section E on Pae 2). X Other(specify e ui ment type and model in Section Tank ID:2 PREMIUM Tank ID: X In-Tank Gauging Probe. Model:VR MAG PROS 1 ❑ In-Tank Gauging Probe. Model: X Annular Space or Vault Sensor. Model:VR 420 ❑ Annular Space or Vault Sensor. Model: X Piping Sump/Trench Sensor(s). Model:VR 208 u Piping Sump/Trench Sensor(s). Model: X Fill Sump Sensor(s). Model:VR 208 ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: X Electronic Line Leak Detector. Model:VR ELLD C Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: 0 Tank Overfill/High-Level Sensor. Model: X Other(spectry equipment type and model in Section E on Pa 2). ❑ Other s d e ui meM ttpt and model in Section E on Pae 2). Dispenser to:1/2 Dispenser ID:7/6 X Dispenser Containment Sensor(s). Model:VR 208 X Dispenser Containment Sansone). Model:VR 208 ❑ Shear velvets). S, Shear Valve(s). Dispenser Containment Floats and Chain(s). nisinenser Containment Floats and Chain(s). Dispenser to:3/4 Dispenser ID: 9/10 X Dispenser Containment Sensor(s). Model:VR 208 X Dispenser Containment Sensor(s). Model:VR 208 U Shear Valve(s). I I Shear Valve(s). Dispenser Containment Floats and Chain(s). Dispenser Containment Floats and Chains. Dispenser ID:5/6 Dispenser to:11/12 X Dispenser Containment Sensor(s). Model:VR 208 X Dispenser Containment Sensors). Model:VR 208 ❑ She Vaive(s). ShearValve(s). Dis nser Containment Floats and Chains ❑ Dispenser Containment Floats and Chain(s). `If the facility contains more tanks or dispensers,copy this forthinclude information for every tank and dispenser at the facility. C. Certification - I certity 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 equlpmei capab o generating such reports,I have also attached a copy of the report;(Cheek all that apply): System set-up ,,./T285 _ Technician Name(print):JAMES DAY Signatu Certification No.: A22740 LicenseTesting Company Name:MID VALLEY CONSULTING Phone N Testing Company Address: 1097 BRONCO DRIVE,PLUMAS LAKE,CA 95961 Date of Testing/Servicing:08/24/20112 Monitoring System Certification Page 1 of 4 RECEIVED NOV 21 2012 SAN JOAQUIN COUNTY 1 ENVIRONMENTAL 2/21/07 HEALTH DEPARTMENT