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Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at hffo://wvvw.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. Gifleet Contact Phone No.: 209-954-0945 Make(Model of Monitoring System:VEEDER ROOT TLS 350 Date of Testing/Servicing: 01/12/2012 B. Inventory of Equipment Tested/Cer ified Check the appropriate boxes to indicatespecific a ui �ment ins acted/serviced: Tank 10:1 UNLEADED Tank ID: DIESEL X In-Tank Gauging Probe. Model: VR MAG PROBE 1 X In-Tank Gauging Probe. Model:VR MAG PROB 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(speWy equipment and model in Section E on Page 2). X Other(specify equipment type and model in Section E on Pa 2). To*ID:2 PREMIUM Tank ID: X In-Tank Gauging Probe. Model:VR MAG PROB 1 ❑ In-Tank Gauging Probe- Model: X Annular Space or Vault Sensor. Model:VR 420 C Annular Space or Vault Sensor Model: X Piping Sump/Trench Sensor(s). Model:VR 208 ❑ 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 - Tank Overfill/High-Level Sensor Model: X Other(specify eqUilifflent type and model in Section E on Page 2). Other(specify equipment and model in Section E on Page 2). Dispenser ID:1/2 Dispenser ID:7/8 X Dispenser Containment Sensor(s). ModeI:VR 208 X Dispenser Containment Sensor(s). Model:VR 208 Shear Valve(s). Shear Valve(s)- Dispenser Containment Floats and Chain(s). Dispenser Containment Floats and Chain(s). Dispenser ID.3/4 Dispenser ID: 9110 X Dispenser Containment Sensor(s). Model:VR 208 X Dispenser Containment Sensor(s). Model.VR 208 Shear Valve(s). Shear valve(s). Dispenser Containment Floats and Chain(s). Dispenser Containment Float(s)and Chemist. Dispenser ID:5/6 Dispenser ID:11/12 X Dispenser Containment Sensor(s). Model:VR 208 X Dispenser Containment Sensor(s). Model:VR 208 Shear Valve(s). Shear Valve(s). Dispenser Containment Floats and Chains _ Dispenser Containment Floats and Chain(s). 'If the facility contains more tanks or dispensers,copy this forth. Include information for every tank and dispenser at the facility. C. Certification - 1 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,1 have also attached a copy of the report;(check all that apply): System set-up Alarm his ry 70Technician Name(print).JAMES DAV Signature: Certification No.: A22740 License. Testing Company Name:MID VALLEY CONSULTING Phone N : )749-9892 Testing Company Address: 1097 BRONCO DRIVE,PLUMAS LAKE,CA 95961 Date of Testi g/Servicing: 01/12/2012 Monitoring System Certification Page 1 of 4 12107 1 3/J1/07