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RECEIVED DEC 14 2010 Appendix VI ENVIRONMENTAL HEALTH (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://wwvP "Fd% MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of Caldomia 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 MakefModel of Monitoring System: Date of-resting/Servicing: 11/5/2010 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate speeiflc aquipmant irtspected/serviced: Tank to 1 UNLEADED Tank to DIESEL In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: X Annular Space or Vault Sensor. Model: VR 420 X Annular Space or Vault Sensor. Model:VR 420 X Piping Sump/Trench Sermons). 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: Other(specify equipment type and model in Section E on Page 2).__ Other(specify equi nt type and model in Section E on Pme 2). Tank ID:2 PREMIUM f Tank ID: In-Tank Gauging Probe. Model: 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 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 Electronic Line Leak Detector. Model: = Tank Overfill/High-Level Sensor. Model Tank Overfill/High-Level Sensor. Model: Otho s -ty equipment type and model in Section E on Page 2)_ Other(specify equipment t and model in Section E on Page 2). Dlspenser to:1/2 Dispenser lD:7/8 X Dispenser Containment Sensors). ModeI:VR 208 ❑ Dispenser Containment Sensor(s). Model:VR 208 Shear Vatve(s). ❑ Shear VaNe(s). Dispenser Containment Floats and grains. riser Containment Ffoat s arW Chains. Dispenser to:3/4 Dispenser ID: 9/10 Dispenser Containment Sensor(s). Model:VR 208 Dispenser Containment Sensor(s). Model:VR 208 Shear Valve(s). Shear Valve(s). _ Dispenser Containment Floats and Chain(s). �_ Dispenser Containment F s and Chain(s). Dispenser ID:5/6 Dispenser ID: Dispenser Containment Sensor(s). Model:VR 208 Dispenser Containment Sensor(s). Model:VR 208 Shear Valve(s). Shear Valve(s). Dispenser Containment Flost s and Chains L 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 Pian showing the layout of monitoring equipment. For any equipment c gable pt generating such reports,1 have also attached a copy of the report;(check all that apply): System set-up Alarm histo Technician Name(print):JAMES DAY Signature: Certification No.: A22740 License.No5 Testing Company Name:MID VALLEY CONSULTING Phone No.:(53 7499892 Testing Company Address: 1097 BRONCO DRIVE,PLUMAS LAKE,CA 95961 Date of Testing/Servicing:11/05/2010 Monitoring System Certification Page 1 of 4 12/07 1 2/21/07