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Appendix VI (Copies of Monitoring System Certification form and LIST Monitoring Plot Plan available at htto7/)`www waterboalga.ce.dov.) MONITORING SYSTEM CERTIFICATION n=or use By A9 Juhsdictlors Within the State ofCalltom/a Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Tide 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment-A separate certification or report most be prepared for each monitoring system watmi panel by the technician who parlor as the work. A copy of this fort must be provided to the tank system ownerloperaKu. 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 Facifrly Name: Mardi&Bianchi Chevron Big-No. SIPS Address: 1918 March Lane City: Stockton 7Ip: 95207 Facility Contra Person: Giyout contactPhoria No.: 20". WD045 Make/Model of Monitoring Syatarn:VEEDER ROOT TLS 360 Dareot Testrg/Servidng' 11/52010 B, inverKuty,of Equipment Tooted/Cortified _check the aoorouH_ate boxes to i_ndicaee_spec Ntcoqtupmewlnr tedlsartrtcouL __- Tank 10:1 UNLEADED Tank KY. DIESEL In-Tank Gauging Probe. Model: ❑ IR-Tank Gauging Probe- Model X Annular Space a Vault Semor. Model VR 420 X Annutar Spare or Vault Samar. Model:VR 420 X Piping Sump/Trench Sensoria)- Model VR 208 X Piping Sump/Trench Senserts). Model:VR Me X fill Sump Sensor(s). Mode(- VR 206 X Fill Sump Semor(s). Model:VR 208 0 Mechanical Lt.Leak DotecWr. Modot D Mechanical Line Leak DetectorMadel: X Electronic Lim Leak Detector. Model. VR ELLD X Electronic Lim Leak Detector. Model: VR ELLD a Teak Overfill/High-Level Sensor. Model n Tank Ovefill I High-Leval Semon Model. X Ottaxu merit_ and to Secoan E m P e X ('X11er In am and"IQ"in Section E on P 2- Tank Ip:2 PREMUM Tank W.- 2 :_1 In-Tank Gauging Probe. Model D In-Tank Gauging Probe. Modet: X Annular Space or Vault Sensor. Model:VR 420 ❑ Annular Space or Vault Sensor. Model: X Piping Sump/Trench Semorts). Model VR 208 Cl Piping Sump/Trench Sensor(s). M066 X Fin Sump sonsor(s). Model:VR 20e ❑ Fal Sump Sensoria). Model. Mechanical Lim Leak Detector Model: D Mechanical Line Leak Detector. Model: X Eledronle Line Leak Detector. Modal VR ELLD 0 Ebettonic Line leak Detector. mamL :i Tank Overfill 1 High-Level Sensor. Model: D Tank Overfill/High-Level Semor. Modet: X c u an and rnotlN in Swim E m P ❑ Olfler 6 a Mtn nd model In S9 Won E on P bispatlaer ID:12 Dispenser 10:7/8 X Dispenser Containment Somor(s)_ ModelVR 208 0 DLspomer Cpnleinmont Sensor(s). Model:VR 208 Shear Velvets), ❑ Shear Valve(p)_ Disoenser Containment F s and Chill s. Di on ContainmaM FI 1 s ark Cnatn s. Dkpemm ID:314 Dlspemer it): 9110 Dispenser Containment Semor(s). Modal:VR 208 D Dispersor Containment Sensor(s). Madoi:VR 208 Shear VaNe(s)- D Shear Valve(%). Dispenser Containial nt Fine & and Chains. mtt Containment Floatia)and Chain(s). Dlsperiser ID:5/6 - Dispenser ID: Dispenser Containment Seruwris)_ Modct:VR 209 ❑ Dispensor Cmfstmtent Sensoria)- Model:VR 200 Shear Valve(s). Shear Velvets)- D nser Cornalrlment Ft at s and Chains D n aro corttainmem Fleets and Chains S. if the facility connem more tanks of dispensers,copy this film, include infonnallm for every lank and dispenser at the facility. C. Certiflicadon - I codify that the equipment idrntiried In this document was impectedlserviand M accordance with the manufacturam' guidelines- Attached to this Caddisadda 16 Interaratlon(e.9.rmnulacrmis'G klista) eeeeary t0 vodty that thio ledennelmn IN corset and a Plot Plan stowing the Layout of monkodng equipment For any equ generating such reports,i have also attached a copy of the report;(shack ail that apply): ` System set-up -j Alarm hi Ot Ted"clan Name(print).JAMES DAY Signature- Codihcation No A22740 License�ol!rj 0986 Tasting Como Company Nan :MID VALLEY CONSULTING Phone 7 Testing Company Address. 1097 BRONCO DRIVE,PLUMAS LAKE,CA 85981 Date Of Testrg/Ser dict g:1110 5/2 01 0 Monitoring system Codimesten Pago i of 4 1=7 1 M1107 E© EVIl-111SN00 A371VAGN Z6866bL0£9 92:b2 BSOZ/0£/ZI