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09/18/2014 06:29 1209331" 73 FLAGCITV CHEVRON PAGE 02/07 <br />Dago 217 <br />09115!201013:58 <br />Appendix 'VI <br />MONITORING SYSTEM CERTIFICATION <br />For Use BV All Jurisdictions Wnhin the State of Callfamia <br />Authority Cited: Chapter 6.T, Health and Safety Cade; Chapter 16, Division 3, 'title 23, Callfornia Code of Regulations <br />ThLs fwm must ba u:td to doedmant testing end WmIcing or moniterinp equlpment. A separate certlfloalion or reportmustbo prepared for <br />each rtmitoring'Y"mcontrolPanel bythet"NOdanwho pdrformathnwork. AcaPYofthl Wrnmust be providd igbrig USTsystemsdelta30 thetank daysoRe�tdate. <br />owner/openttrn. Tho ownarloporstor munt xubmlt a Copy ofthl t roan to this local agonry mgu <br />A. Cieneralll-mrmadon <br />Facility Name: FLAG Cr" CHEVRON Bldg' No.: <br />Site Address: 8421 CAPITAL. CAty; LODI Zip: 85242 <br />Facility Contact Contact Phone No,; 200 334-0915 <br />Person: <br />MakefModel dfMonitorin9 Syntem1 VREDER ROOT TL8 300 Dote of TestingJServlcing: 8AU201? <br />B. Inventory of Equipment Teatmdlt.,enl9ed <br />Chock thea to date boxes to indicates eciflc e I mont in actedl4erviced: <br />Tank ID: 87 <br />Tar* ID; 91 <br />N in•Tank Gauging Probe. Madel; MAC 1 <br />9 In -Tank Geuginp Probe, Model: MAG 1 <br />19 Annular Space or. Vaudt Sarmor. Modal: 409 <br />3 Ahnudar Space or Vault Sw%br. Modal: 400 <br />* Piping Sump I Trtmch Swwr(s), Model: 205 <br />3 Piping Sump 1 Trench Sensdr(s). Model: 208 <br />* Fill Sump Senser(s). Modal: 208 <br />9 Fill Sump :*msnr(y). Model: 208 <br />N Mechanical Une Leak Detectat. Mode[: Pr PETRO <br />0 Machanlcal Lltto Leak Detector. Model: FE PETRO <br />Electronic ljne Leek Dotoctor, Model; <br />f3 peetrordc Linc Leak Dotertar. Madel <br />[] Tank Ov"I / HIgh.Level Sensor, Model <br />0 Tank Overtlll I H h -Level Sensor. Model: <br />Oaror (specNy equipment typo and model In Sottion E on Page 2), <br />Q Other (Voeity equprnnnt type and model in Saotlon E on Page 2). <br />Tank 1D: DIE <br />Tank ID: 87 SYPON <br />In in -Tank Gnuong Proba. Modal: MAC 1 <br />Z Irl•Tdhk Gauping Probe. Model; 10A 1 <br />K Annutdr Wee or VaultSnrt wr. Model; 409 <br />[9 Annular Space or Vault Samar. Model: A09 <br />0 Plpinq Sump / Trench Sensor(s). Model: 208 <br />(a Piping Sump 1 Trench Sonsor(s), Model: 208 <br />0 FIII Sump Sensor(s), Model: 200 <br />1 ® i40 Sump Samw(s). Model; 208 <br />OR Maetttattaal Una Leak Detector, Model: LO 2000 <br />0 Mecndnical Line Leak neatctor. Madel: FE PETRO <br />0 Electronic Una Leak Detector, Madd: <br />Electronic Una Leak Detector. Model; _ <br />Q Tank Overfill I Hk)tFLww Sancor. Model; <br />❑ Tank Overfill / Hlgh-Laval Sensor. Model: <br />[] other(spoNly equipment typo and modal In Section E on Pogo 2). <br />0 Other (specity aqulpmenttype and model In Section E an Pogo 2), <br />Dispenser ID; 1.7. <br />Dispenser ID: 3•4 <br />S Dispenser Cortilnmont Sonsor(s). Model: 200 <br />01spanser Ccnteinmortt Sonsor(s), Model: 208 <br />lS ShearVeitve(s). <br />2 8hearValve(5). <br />0 011mensar Containment Floats) and Chaln(s). <br />0 Digpansar Cantainmain Float(r) rind Chein(s). <br />Di9permar lD: 5.8 <br />Dispenser ID: 7.8 <br />0 Dlcpont or Containment Sensor(a). Model: 208 <br />19 Dispenser Contglnment Senaar(s), Model: 208 <br />I& Shear V."!;). <br />14 Sheer Vatve(s). <br />C] Dispenser Containment Float(,) and Chain(s). <br />Q gispnrr_nr Containment Flougs) and Chah(s). <br />Dispenser ID: 9.10 <br />Dlsprinser 113; 11.12 <br />10 Qlspenser Containment <br />(Fa Lt�mnowr containmant sansor(s). Model; 208 <br />Satser(s). Model: 208 <br />Sheer VnIV0(s), <br />® Shear Valve(s). <br />Q Dispenser Containment Float(s) and Chaln(s). <br />[ Dispenser Containment Float(s) and Chaln(s). <br />'Ifttte facility contains morb tank, or disponsers, copy this Ibmt, Indudo Information for overytenk and dispenser at the f4elkly. <br />C. emMeaden - I certny that the egWpment Identified In this document Waa Inspectedleervlced M accordance With the manuracturem, <br />guidelines. Attached to nits cMffcatlon Is Infarmetlon (e g. manuracturem, checklists) necessary to verify that this irtfortnation is correct <br />and a Piot plan shoring the tryout of marl terktg equlpmelt. For any equipment eapa6fe of generating such reports, I havd also attached a <br />copy or the report; (nArrkdrrakartrp/ltp): 0 system set-up in Alarm (tl91turyreport <br />Tachnicatn Nerve (Pant); FELIX RAMIREZ Signature; <br />Certlficadon No.: 834976 License Me: S273934 -UT 091740 OTTL <br />Tasting Company Narw A1:FORUM7EV _ Phone Nb, 2E0, 7440113 <br />TestMgCompanyAddress; 4152 ST° RE � TOA 95632 DateofTesth91Stk�v W9_', 09.04.13 <br />Monitoring System ceruncanon Pogo 1 of 4 2/21/07 <br />