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May 2516 08:54a p'2 • • C�l��i�C�C�L Appendix VI MAY 2 5 2016 (Copies of Monitoring System Certificabon form and UST Monitoring Plot Plan available at MtP:1 www w t6s'.ta p YF-M 1!;'--1,Ik_. l6dDArtt,t eepp�AtYt'gtlO:Ne+' MONITORING SYSTEM CERTIFICATION For Use By AN Jurisdictions Within the State of Celtiomia Authority Cited.Chapter 6.7, Health and Safety Code;Chapter 16, Division 3, Title 23, California Code of Regulations This tone must be used to document testing and servlGng 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 ownerloperator must submit a Copy of this farm to the local agency regulating UST system within 3C days of test date. A. General Information Facility blame: FAST AND EASY Bldg.No.: Site Address: 10878 N.HVJY 99 City: STOCTON CA, Zip: 95212 Facility Cornett Person: MIKEALE Contact Phone No.: MakeJModel of Manilorirng System: VEEDER ROOT TLS 350 Date MTesting/Servicing: 4125/2016 B. Inver"of EquipmentTestedlCertified Cheek the appropriate,boxes to indicate specific equipment ins eetediservieed: Tank ID:1 SUPREME Tank t6 UNLEADED X In-Tank Gauging Probe. Modal:VR MAG PROS X In Tank Gauging Probe. Model: VR MAO PROS X Annular Space or Vault Senses. Model:VR 420 X Annular Space or Vault Sensor. Model: VR 420 X Piping Sump f Trench Sensor(s). Model:VR 200 X Piping Sump!Trench Sammie). Model: VR 208 Fill Sump Sersor(s)- Model: ❑ Fig Sump Sensor(s). Model: X Mechanical Line Leak Detector. Model:RFD JACKET FXIV X Mechanical Line Lesk Detector- Model: RED JACKET F)W Electronic:Lire Leak Defector. Model: ❑ Electronic Line Leak Detector- Model: Tank Overfill I High-Level Sensor. Model: ❑ Tank Overfill I High-Level Sensor Model: Other(specify equipment a and model in Section E on Pam 21. ❑ Otter e i marl type and model in Section Eon Pe 2), Tank 111i PLUS Tank to: DIESEL X In Tank Gauging Probe. Model:VR MAG PROS X to-Tank Gauging Probe. Model: VR MAG PROS X Annular Space or Vault Sensor. Model:VR 420 X Annular Space or Vault Sensor Model: VR 420 X Piping Sump I Trench Sensor(s), Model:VR 208 X Piping Sump/Tranch Senors). Model: VR 208 FII Sump Sensor(s). Model: ❑ FII Sump Sersor(s}. Model: X Mechanical Line Leak Detector. Model:VMI LD 2000 X Mechanical Line Leek Detector. Model:RED JACKET FXIV Electronic Line Leak Detector. Model: ❑ Electronic Line Look Detector. Model: Tank Overfill I Hlghlevel Sensor. Model ❑ Tank Overfill f High-Level Sensor Model: Others G equipment type and model In Sedlon E on Pae 21. ❑ other ispecify equipment and model in Section E on Page2. Dispenser ID:112 Dbparwer ID:718 Disperser Comaimem Sensor(s). Model: D Dispenser Containment Serpi Model ❑ Shear Valva(s). ❑ Shear Valves). X Dispenser Containment ment Floats and Chains.BROVO X Disperser Contalnmer it Floats and Chains.SROVO Dispenser li 314 Dispenear tD: 9110 D DispenserOonlstarerd SOMON(s)- Model: D Dispenser ContainmentSensor(s). Model: Shear Valve(s). F Shear VaNe(s). X Dispenser Containment Floats and Chains.BROVO Djspeuser Containment Foals and Chains. Dispenser ID:518 Dlspanser ID: ❑ DispenserContainment Sensor(s). Model: L Dispenser Containment Sensar(s). Madel: ❑ Shear WOR(s). r Shear VaNe(s)- X Dis ensef ContaimTeM Floats antl Chains BROVO L Dia miner Containment Fli and Chain sl. -if the facility contains more tanks or dispensers.copy this farm. include information far every tank and dispenser at the Facility. C. Certification - I certify that the equipment identified In this document was Inspected/sendi in accordance with the manufacturers' guidelines. Attached to this Cenlficadon Is infomtatlon(e.&manufacturers' checklists)recessary to verity that this information is correct and a Plot Plan showing the layout of monitoring equipment For any equipment capable of generating such reports,I have also attached a Copy of the report:(Check erg that appty): ❑system set-up C Alarm history report Technician Name(pnni JASON HAASE Signature: Certification No.: B40970 License.NO.: 920985 Testing Company Name:MID VALLEY CONSULTING Phone No.:(530)749.9892 Testing ComparryAddness: 1097 BRONCO DRIVE,PLUMAS LAKE,CA95951 Date of TestingiSeMcing: 4!2512016 Monitoring Satan Certification Page 1 of 4 12107 1 2/21/07