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RECEIVED <br />Appendix V1 JAN 10 2013 <br />(Caples Of Monitoring System Certification form and UST Monitoring Plot Plan available at ha//VAwb FNTA <br />L <br />MONITORING SYSTEM CERTiFICATION MENT <br />Uso By All Jurladiabrorl,2 <br />n the Stats <br />Authority Cited: Chapter 8.7, Health and Safety Code �Cht apter 16,aDvis on 3, Title 23, CalFfornta Code of <br />Regulations <br />This forth must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for <br />68th monitoring system control panel by tha technician who performs the work. A copy of this form must be Provided to the tank system <br />awrlerioperator, The Ownerfoperator must submit a copy of this forrn to the local agency regulating USS' systems within SO days of test data. <br />A. General Information <br />Facility Name: FLAGE CITY CHEVRON Bldg, No.: <br />SileAddress; 6421 CAPITAL City: 1.00i Zip, 95242 <br />FacilityConfect Person: PAT MULMA1_L, <br />Metro/Memel of Monitoring Syetem: VE=EIDER ROOT TL8 $50 <br />B. <br />inventoryof Equipmeht Tested/Certified <br />Check the appropriate boxea to Indicate specific aqulpn <br />TAnk ID; i SUPREME <br />t SUPREi�E <br />- <br />X <br />In -Tank Gauging Probe. <br />Modal: VR MAG PROS <br />X <br />AnnUlar Space or Vault Sensor, <br />Model: VR 407 <br />X <br />Piping Sump I Trench Sens6gs), <br />Modes: VR 208 <br />X <br />X <br />rill Sump Sensor(s). <br />Model. VR 208 <br />Mechanical Line Leak Detector, <br />Modal: FE PETRO <br />❑ <br />Electronic Line Leak Detector. <br />Model; <br />0 <br />Tank Overfill / High -Level Sensor. <br />Model: <br />Tank 10:2 UNLEAVED MASTER <br />X in -Tank Gaugino Probe. <br />X Annular Space or Vault Sensor. <br />Piping Surip (Trench Sensor(a). <br />Fill Sump sensor(s). <br />X Mdchorilcel Line Leak Detector. <br />U Electronic Line leak Detector. <br />q Tank Overftl 1 Hlgh-Level Sensor, <br />DispenserlD, 112 <br />X 01spenser containment Sonsor(s). <br />Q Shear Valve(s). <br />Dispenser ID: 314 <br />X Dispenser Containment Sensor(s). <br />❑ Shear Valve(s). <br />Model: VR MAG PRDB <br />Model: VIS 407 <br />Model. VR 206 <br />MOd6l: VR 206 <br />Model: FE PETRO <br />Model: <br />Modek <br />Model: VR 208 <br />Model: VR 208 <br />Contact Phone No,: 680-7813*2275 <br />bate of TWIng/Se1vlciil9: 9128/2012 <br />Tank Iq: ULEADED SLAVE <br />X in -Tank Gauging Probe_ <br />X Annular Space or Vault Sensor, <br />X Piping sump ! Trench Sensor($). <br />X Fill Sumpp Sensor(s), <br />X MecJlenlcal Line Leak Detector. <br />Q Electronic Line Leek Detector. <br />❑ Tank OVertill / High -Lava) Sensor. <br />Tank ID: DIESEL. <br />X In -Tank Gauging Probe. <br />X Annular Space or Vault Sensor. <br />X Piping -sump / Trench Sensor(s). <br />X Flit Sump Sensor(&). <br />X Mechanical Line Leak Detector, <br />0 Electronlc Line Leak Detector. <br />Q Tank Overall / High -Level Sensor. <br />bispanser ID; 718 <br />X Dispenser Containment Sensor(s). <br />C Shear Valve(s). <br />Dispenser Containment Floats and <br />DispenserlD: a/16 <br />X Dispenser Containment Sensor(s), <br />G Shear Valve(s). <br />Model: VR MAG PRDB <br />Model; VR 407 <br />Model: VR 208 <br />Model: VR 208 <br />Model: FE PETRO <br />Model: <br />Model: <br />Modal: VR MAG PROS <br />Model: VR 407 <br />Model. VR 208 <br />Model: VR 206 <br />Model: VMI LD 2000 <br />Modal: <br />Model; <br />at In Section E on Pane <br />Model: VR 208 <br />Model: VR 208 <br />Dispenser ID: 516 Dispenser iV. <br />X Dispenser containment Sensom(s), Model; VR 208 X Dispenser Coptairlment Sensor($), Model: VR 08 <br />U ShearValve(s). ❑ Shearvalve(s). <br />Dls enser Containment Floats and Chains D Dis enser Containment Floats and C alas . <br />`If the facility contalns more tanks or dispeM80m, copy this form. Include Information for every tank and dispenser at the facirity. <br />C. Certifioation - I certify that the equipment identified In this document was Inspected(servlced in accordance with the Manufacturers' <br />guidelines. Attached to this Certification Is information (e,0. Manufacturers' oheckilstO nec@ssM to verify that this information Is Correct <br />and a plot Plan ehowing the layout of Monitoring equipment, For any oqulpme t ca pie of generating such rerports, I have also attached a <br />C opy of the report. (chockaff 11m,e/applyi, ❑ systatnsat-up ❑Alarm hl ry ort <br />Technician Name (print): JAMES DAY Signature: <br />Cerilfcation No.: A22740 License. No,: 255 �— <br />Tasting Company Name: MiD VALLEY CONSULTING Phone No.:(53 749.9892 <br />Testing Company Address: 1097 BRONCO DRiVE, PLLIMAS LAKE, CA 85961 Date of TestingtSeivlcing_- 9/281Pr)12 <br />Monitoring System Certification <br />1-1 <br />Page 1 of 4 <br />92107 <br />2/21/07 <br />