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Appendix VI MONITORING SYSTEM CERTIFICATION AfAR 0,6111l For Use By All Jurisdictions Within the State of California 611 A/1 20V Authority Cited:Chapter 6.7,Health and Safety Code;Chapter 16,Division 3,Title 23, California Code of This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be H each monitoring system control panel by the technician who performs the work.A copy of this form must be provided to the tOwner/operator.The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days test tlate. TH 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 Mondodng System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 2/21/2017 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: 87 Tank Size: Tank ID: 91 Tank Size: E In-Tank Gauging Probe. Model: MAG 1 E In-Tank Gauging Probe. Model: MAG 1 E Annular Space or Vault Sensor. Model: 409 ® Annular Space or Vault Sensor. Model: 409 ® Piping Sump/Trench Sensor(s). Model: 208 E Piping Sump/Trench Sensor(s). Model: 208 ® Fill Sump Sensor(s). Model: 208 E Fill Sump Sensor(s). Model: 208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model'. PLLD ® Electronic Line Leak Detector. Model: PLLD ❑ Tank Overfill/High-Level Sensor. Model. ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Othereci s equipment ( p y type and model in Section E on Page 2). Tank ID: 89 Tank Size: Tank ID: Tank Size: E In-Tank Gauging Probe. Model: MAG 1 ❑ In-Tank Gauging Probe. Model. E Annular Space or Vault Sensor. Model: 409 ❑ Annular Space or Vault Sensor. Model: E Piping Sump/Trench Sensor(s). Model: 208 ❑ Piping Sump/Trench Sensor(s). Model: E Fill Sump Sensor(s). Model. 208 ❑ Fill Sump Sensor(s). Model. ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: E 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 DispenserlD: 7-8 E Dispenser Containment Sensor(s). Model. 208 E Dispenser Containment Sensor(s). Model: 208 E Shear Valve(s). E Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chaints). Dispenser ID: 3-4 DispenserlD: 9.10 E Dispenser Containment Sensor(s). Model: 208 E Dispenser Containment Sensor(s). Model: 208 E Shear Valve(s). E Shear Valve(s). ❑ Dispenser Containment Float(s)and Chaints). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5.6 Dispenser ID: 11-12 E Dispenser Containment E Dispenser Containment Sensor(s). Model: 208 Sensor(s). Model: 208 E Shear Valve(s). E Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Cl '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;(check all that apply): E System set-up E Alarm history report Technician Name(print): David Winkler Signature. Certification No.: 5263373-UT License No: 08-1739 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0112 Testing Company Address: 416 2n°STREET GALT,CA 95632 Date of Testing/Servicing: 2-21-17 Monitoring System Certification Page 1 of 4 2/21/07 'PR02�t41R� c ��