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JAN .10.2013 9:23PM CORNELIUS NO.8- EIVE'D Appendix Vi JAN 10 2013 (COPles of Monitoring System Certiflcation form and UST Monitoring Plot Plan available at htt :(hhrAW t QTAL TEM CERTIFICATIONMONITORING SYS NT For Uso By All Jur4sdiojioris Wthir, the State of Californila Authority Cited: Chapter 6.7, Heaith 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 pertorms the work. A Copy of this €oral must be provided to the tank system Owner/eperator, The owner/operator must submit a copy of this form to the Iocai agency regulating UST systems within 30 days of test date. A. Generallnformation Facility Name; FLAGE CITY CHEVRON Bldg, No.: SilsAddress: 6421 CAPITAL Facility Contact Person: PAT MULHALL MekolModel of Monitoring Sy&tem: VEEDER ROOT TLS 350 B, inventory of Equipment Tested/Certified Check the aepropriate boxes to Indicate _specific _no Tank ID; 1 SUPRF-ME X In -Tank Gauging Probe, Model- VR MAG PROS X Annular Space or Vault Sensor, Model: VR 407 X Plpfng Sump / Trench Sensor("), Model: VR 208 X Fill Sump Sensor(s). Model: VR 208 X Mechanical Line Leak Detector Modal: FE PETRO ❑ Electronic Line Leak DeteOtor, Model: 0 Tank Overfili I High -Levet Sensor, Model: L Others gel o ul ment tv a and modal In Sectlon E on Pape Tank iD:2 UNLEADED MASTER X In -Tank Gauging Probe. Model, VR MAG PROS X Annular Spars or vault Sensor. Modes; VR 407 Piping Sump /'ranch Sensor(s). Model: VR 206 Fill Surno Sensor(s), Model: VR 206 X Mechanical Llne Lsak Detector. Model: FE PETRO U Electronic Line Leak Detector, Model; C Tank Overfill I HIgh-Level Sensor, Model: u Other (specify equpment type and model In Section E on Pace: Dispenser ID; 1/2 X Dispenser Containment Sensor(s). Model: VR 208 D Shear Vaive(s), Dispenser Containment Fioat(s) and Chain(s),_.,_ Dispenser iD:314 T_ X Dispenser Containment Sensor(s), Model: VR 20t :1 shear valve(s). Dispenear ID: 516 ' X Dispenser Containment Sensor("), Model: VR 208 ❑ Shear Valve("). Dispenser Containment Floats) and Chains 'If the facility contains more tanks or dlspens0M, copy this form. In City: LODI gip; 966242 COMact Phone No,: 530-788.2275 Date ofTQsting/Servicing: 9/28/2012 Tank Ib: ULEADED SLAVE X In -Tank Gauging Probe_ Model: VR MAG PROS X Annular Space or Vrsuit Sensor. X Plplrlg Sump I Trench Sensor(&). Model: VR 407 Model: VR X Fill Sump Sensor(s). 20a Model; VR 206 X Macilanlcal Line Leak Detector. Model: FE PETRO 11 Electronic Line Leak Detector. Model: ❑ Tank Overfill I Nigh -Level Sensor, Model: D Others eci o u ment type, and modal In Section E on Page ; Tank ID: DIESEL X In -Tank Gauging Probe, Model; VR MAG PROS X Annular Space or vault Sensor. Model: VR 407 X Piping Sump/Trench Sensor(s), Model: VR 208 X Ftll Sump Sensor(&). Model: VR 246 X Mechanical Line Leak Data=r. Model: VMI LD 2000 Electronic Line Leak f7etector. Model: ❑ Tank Overfill I High -Leval Sensor. Model: r; Other (seacILSquIpmentlype and model In Section E on Page, Dispenser iD: 7(8 X Dispenser Containment Sonsor(s). Model: VR 208 L'� Shear Vaive(e). Dis enser Containment Floatand s Chains . Dlsponser ID: 8/j0 X Dispenser Containment Sensor(s), Model: VR 208 Q Shear Vaive(s). Dls enser Containment Floats and Chain & . Dispenser ID: X Dispenser Containment Sensor(s). Modal: VR 08 ❑ Shear ValvG(s), D Dis enser Containment Floats and Chain(s). Tilton for every tank and dispenser at the facility, C. Certification - I certify that the equipment Identified In this document was InspectOd/serviced In accordance with the manufacturers' guidellnos. Attached to this Certification is information (a.0. manufacturers' checklists) necessary to verify that this Information Is correct and a Plot Plan ehowing the layout of monitoring equipment, For any equipme t capblo of generating such reports, I have alto attached a copy of the report; (chock&u thatapply). ❑ System tet -up E Alarrn hi r9 ort Technician Name (print): JAMES PAY Signature: J Certification No.; A2274Q License. No,: 955 Testing Company Name: MID VALLEY CONSULTING Phone No.:(53 748-9892 Testing Company Address: 1097 BRONCO DRIVE, PLUMAS LAKE, CA a6061 Data Of TestInWServicing__ 9IPal2012 Monitoring System Certificatlon Page 1 of 4 12/oy 1 2/21/07