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V 1.6.r JAN 14 2015 Appendix VI ENVIRONMENTAL HEALTH PERMIT/SERVICES (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at httD://www.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 Testing/Servicing: 11/18/2014 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment ins ctecilserviced: 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 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(specify equipment type and model in Section E on Page 2). X Other(specify equipment a 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 CI Piping Sump/Trench Sensor(s). Model: X Fill Sump Sensor(s). Model:VR 208 F! 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: X Other(specify equipment a and model in Section E on Page 2). Other(specify equipment type and model in Section E on Pae 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 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 Floats and Chain(s). Dispenser Containment Floats and Chain(s). Dispenser ID:5/6 Dispenser ID:11/12 X Dispenser Containment Sensor(s). Model:VR 208 X Dispenser Containment Sensor(s). Model:VR 208 0 Shear Valve(s). - Shear Valve(s). Dispenser Containment Floats and Chain s -t 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'check)sts) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment For any equipmerrtcable of generating such reports,I have also attached a copy of the report;(check all that apply): System set-up _AI rm history port Technician Name(print):JAMES DAV Signature: Certification No.: A22740 License.No.: 9 985 Testing Company Name:MID VALLEY CONSULTING Phone No.:(5 )749-9892 Testing Company Address: 1097 BRONCO DRIVE,PLUMAS LAKE,CA 95961 Date of Testing/Servicing:11/18/2014 REVISED 1/92015 Monitoring System Certification Page 1 of 4 12/07 1 2/21/07