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_ RECEIVED Appendix VI NOV 27 2012 (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http,//www.waterboards.ca.gov.) IRONMENTALHEALTH MONITORING SYSTEM CERTIFICATIOI PERMIT/SERVICES 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 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 ownerloperator 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: QUICKI KLEEN Bldg.No.: Site Address: 707 E YOSEMITE AVE City: MANTECA Zip: Facility Contact Person: FRANCENE ESCABAR Contact Phone No.:(_209 8143726 Make/Model of Monitoring System: TLS 350 Date of Testing/Servicing:_11_/_14_/_2012_ B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific a ui ment tris d/serviced: Tank ID:TANK 1 SOUTH 10 K REG UNL Tank ID: DIESEL X In-Tank Gauging Probe. Model:MAG 1 X In-Tank Gauging Probe. Model: MAG 1 X Annular Space or Vault Sensor. Model: VIR 408 X Annular Space or Vault Sensor. Model: VIR 408 X Piping Sump/Trench Sensor(s)_ Model: VIR 208 X Piping Sump I Trench Sensor(s). Model: VIR208 X Fill Sump Sensor(s). Model:SAME X Fill Sump Sensor(s). Model: SAME X Mechanical Line Leak Detector. Model: X Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model* ❑ Tank Overfill/High-Level Sensor. Model: X Other(sp2cify equipment!Me and model in Section E on P e 2). X Other(specify equipment t e and model in Section E on Pae 2). Tank ID:TANK 2 MIDDLE 5K REG UNL Tank ID: X In-Tank Gauging Probe. Model; MAG 1 ❑ In-Tank Gauging Probe. Model: X Annular Space or Vault Sensor. Model: VIR 408 ❑ Annular Space or Vault Sensor. Model: X Piping Sump/Trench Sensor(s). Model: V/R 208 Piping Sump/Trench Sensor(s). Model: X Fill Sump Sensor(s). Model: SAME -- Fill Sump Sensor(s). Model: X Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: X Other(specify a ui ment type and model in Section E on Page 2). ❑ Others ci ui ment type and model in Section E on Page 2). Dispenser 10: 1/2 Dispenser ID: 7/8 X Dispenser Containment Sensor($). Model: 208 X Dispenser Containment Sensor(s). Model* 208 X Shear Valve(s). X Shear Valve(s). Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: 3/4 Dispenser ID: X Dispenser Containment Sensor(s). Model: 208 ❑ Dispenser Containment Sen$er(s). Model: X Shear Valve(s). n Shear Valve(s). Dispenser Containment Floats and Chain(s). Dispenser Containment Floats and Chain(s). Dispenser ID: 5/6 Dispenser ID: X Dispenser Containment Sensor(s). Model: 208 Dispenser Containment Sensor(s). Model* I X Shear Valve(s). Shear Valve(s). - Dispenser Containment Floats and Chains _: Dispenser Containment Floats and Chain(s). 'I `If the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility. C. Certification - 1 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 gpaple o generating such reports,I have also attached a copy of the report;(check all that apply): System set-up Alarm historye b - Technician Name(print): GREG KAISER Signature: Certification No.: A25983 License.No.: Testing Company Name: KAISER COMMERCIAL PETROLEUM one No.:L209j_401 2379 Testing Company Address: 331 N HEWITT RD LINDEN CA 95236 Date of Testing/Servicing:_111-1-14–if-20112 Mont orirg System Certification Page 1 of 4 12/07 1 2/21/07