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-- -- RECEIVE® 9171 9890 0935 0084 8373 77 JAN 0 2 2015 _ Appendix VI (Copies of Monitoring Systei _.._4f7_1 .,,,1 9890 0935 008g 8373 77 RON E �{Fp�TM� ,,�m�u uo i rvun iuunn nuc nasi aveuauia at httD �?:EaOW. MONITORING SYSTEM CERTIFICATION For Use Use By Alt 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: Gilieet 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 ectedlserviced: 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 PROS 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 Semor(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 equi ment type and model in Section E on Pae 2). X Other(specify equipment a and model in Section E on Page 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 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: X Other(specify enuioment type and model in Section E on Pa 2). ❑ Other(specify equipment a and model in Section E on Page 2). Dispenser ID:1/2 Dispenser to:7/8 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: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 ❑ Shear Valve(s). ❑ Shear Valve(s). Dispenser Containment Floats and Chains 1 ❑ Dispenser Containment Floats and Chains. •If the facility contains mom tanks or dispensers,copy this form. Indude 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'c edRl' fs) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment For any equip ent ca able of generating such reports,I have also attached a copy of the report;(check all that apply): ❑System set-up Alarm story Technician Name(pant):JAMES DAY Signature: Certification No.: A22740 License.No.: 9209 Testing Company Name:MID VALLEY CONSULTING Phone No.:(530)7 9892 Testing Company Address: 1097 BRONCO DRIVE,PLUMAS LAKE,CA 95961 Date of Tesfing/Servicing:11/18/2014 Monitoring System Certification Page 1 of 4 12/07 m22& A-i 'gz V'Q 5YA 1 2/21/07