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Appendix VI MAR j 211 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 forth 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 forth to the local agency regulating UST systems within 30 days of test date. A. General Information: Facility Name: TRACY CHEVRON Bldg.No.: Site Address: 3775 TRACY BLVD City: TRACY CA Zip: 96376 Facility Contact Person: DEBBIE Contact Phone No.: (-8369422) Make/Model of Monitoring System: VEEDER ROOT TLS 360 Date of Testing/Servicing: 2121/2017 B. Inventory of Equipment Tested/Certified Check the aggropriate boxes to indicatespecific equipment ins ectad/serviced: Tank ID: 87 Tank Size: Tank ID: 91 Tank Size: S In-Tank Gauging Probe. Model: MAG 1 S In-Tank Gauging Probe. Model: MAG 1 S Annular Space or Vault Sensor. Model: 409 S Annular Space or Vault Sensor. Model: 409 S Piping Sump/Trench Sensors). Model: 208 S Piping Sump/Trench Sensors). Model: 208 S Fill Sump Sensor(s). Model: 208 S Fill Sump Sensor(s). Model: 208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: S Electronic Line Leak Detector. Model: PLLD S Electronic Line Leak Detector. Model: PLLD Cl 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 equipment type and model in Section E on Page 2). Tank ID: 89 Tank Size: Tank ID: Tank Size: S In-Tank Gauging Probe. Model: MAG 1 ❑ In-Tank Gauging Probe. Model: S Annular Space or Vault Sensor. Model: 409 ❑ Annular Space or Vault Sensor. Model: S Piping Sump/Trench Sensors). Model: 208 ❑ Piping Sump/Trench Sensors). Model: S Fill Sump Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: S Electronic Line Leak Detector. Model: PLLD ❑ Electronic Line Leak Detector. Model: ❑ 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 equipment type and model in Section E on Page 2). Dispenser ID: 1-2 Dispenser ID: 7.8 S Dispenser Containment Sensor(s). Model: 208 S Dispenser Containment Sensor(s). Model: 208 S Shear Valve(s). S Shear Valve(s). ❑ Dispenser Containment Floats)and Chairi ❑ Dispenser Containment Floats)and Chain(s). DlspenserlD: 3.4 DispenserlD: 9-10 S Dispenser Containment Sensor(s). Model: 208 S Dispenser Containment Sensor(s). Model: 208 S Shear Valve(s). S Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Floats)and Chain(s). Dispenser ID: 5-6 Dispenser ID: 11-12 S Dispenser Containment S Dispenser Containment Sensors). Model: 208 Sensor(s). Model: 208 S Shear velvets). S Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chains. '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 Plan showing the layout of monitoring equipment.For any equipment capable of generating such reports,I have also attached a copy of the report;leank all that apply): S System set-up S Alarm history report Technician Name(print): David Winder Signature: VVVO Certification No.: 5263373-UT License No: 8-1739 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0112 Testing Company Address: 416 2-STREET GALT CA 95632 Date of Testing/Servicing: 2-21-17 Monitoring System Certification Page 1 of 4 2/21/07