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RECEI' D Appendix VI Nov 09 2T, (Copies of Monitoring System Certification form and UST Monitoring Plot IP+E"�y�y cO�g��(09L@y vww.waterboards.ca.gov.) MONITORING SYSTEM CE 11F�flf l&Al l(VN For Use By AN Jurisdictions Within the State of Califomia 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: Gilleet Contact Phone No.: 209-954-0945 Make/Model of Monitoring System:VEEDER ROOT TLS 350 Date of Testing/Semcing: 11/0412011 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment ins ed/serviced: Tank 1D:1 UNLEADED Tank ID: DIESEL X Ir Tank Gaugiog 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 Sensons). 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 and model in Section E on Pae 2). X Other(specify equipment type and model in Section E on Pae 2). Tank 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 Annular Space or Vault Sensor. Model: X Piping Sump/Trench Sensor(s). Model.VR 208 Piping Sump/Trench Sensor(s). Model: X Fill Sump Semor(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 F� Electronic Line Leak Detector. Model: 0 Tank Overfill/Hgh-Level Sensor. Model: E Tank Overfill/High-Level Sensor. Model: X Other(specify equipment type and model in Section E on Pae 2). Other(specify equipment type and model in Section E on Page 2). Dispenser ID:1/2 Dispenser to:7/8 X Dispenser Containment Semor(s). Model:VR 208 X Dispenser Containment Sensor(s). Model:VR 208 ❑ Shear Velvets). Shear Valve(s). Dispenser Containment Floats and Chain(s). Dispenser Containment Floats and Chains. Dispenser to:3/4 Dispenser ID: 9/10 X Dispenser Containment Sensor(s). Model:VR 208 X Dispenser Containment Sensor(s). Model:VR 208 ❑ Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s)and Chain(s). Dispenser Con tainment Floats and Chain(s). Dispenser 10:5/6 Dispenser to:11/12 X Dispenser Containment Sensor(s). Model VR 208 X Dispenser Containment Sensor(s). Model:VR 208 ❑ Shear Valve(s). Shear Vahre(s). Dispenser Containment Floats and Chains 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 - 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,I have also attached a copy of the report;(check all that apply): System set-up Alarm histo ne Technician Name(print).JAMES DAY Signature: Certification No.: A22740 License.N .: 0985 Testing Company Name:MID VALLEY CONSULTING Phone No: 0)749-9892 Testing Company Address: 1097 BRONCO DRIVE,PLUMAS LAKE,CA 95961 Date of Testing/Semddng:11/04/2011 Monitoring System Certification Page 1 of 4 12107 1 2%21;07