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RECEIVE® JAN 0 2 2015 Appendix VI {��T41 (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at htto: IR Na0S:L0.' V) 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, Califomia 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 to: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 t and model in Section E on Page 2). X Other(specity equipment t e and model in Section E on Pae 2). Tank ID:2 PREMIUM Tank to: 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: Li 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 Pae 2). Other(specify equipment a and model in Section E on Pae 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). 11 ShearValve(s). Dispenser Containment Floats and Chain(s). Dispenser Containment Floats and Chains. Dispenser ID:3/4 Dispenser to: 9/10 X Dispenser Containment Sensor(s). Model:VR 208 X Dispenser Containment Sensor(s). Model:VR 208 -7 Shear Valve(s). ❑ Shear Valve(s). Dispenser Containment Floats and Chains. Dispenser Containment Floats and Chain(s). Dispenser to:5/6 Dispenser ID: 11/12 X Dispenser Containment Sensor(s). Model:VR 208 X Dispenser Containment Sensor(s). Model:VR 208 l Shear Valve(s). ❑ Shear Valve(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 - 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 e" ts) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment For any equip -int ca able of generating such reports,I have also attached a copy of the report;(check all that apply): System set-up i Alann (story r ort Technician Name(print):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,CA95961 Date of Testing/Servicing:11/18/2014 Monitoring System Certification Page t of 4 12107 1 2/21/07