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09/18/2014 06:37 120933""73 FLAGCITY CHEVRON PAGE 02107 <br />laagc 217 <br />09!151201 k=13:50 <br />Appendix 'VI <br />MONITORING SYSTEM CERTIFICATION <br />For Use Icy All Jurisdlctlons Within the state of Galifornla <br />Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, DiAslon 3, Title 23, California Code of Regulations <br />ThL% form must ba uSbd tD dorarmantteating end wmeing ormonitorinn sgvlprrennt. A%aparate corti ieacon or rapart mu%t be prepared for <br />each monkoring system control panel by tho technician who pcwW=thn work. A copy of this 1t7nrt must ba provided to the tank ry<tam <br />owner/operate, The own5r1615arator mutt xubmIt a copy ofthln brm to thn laced agonty regulating NST rns wflhin 30 days ofta:d date. <br />A. Cieneral Information <br />Facilely Name: FLAG crr)r CHEVRON Bldg, No.: <br />Site Address: 0421 CAPITAL. City: LCO Zip: 95242 _ <br />FaciRy Contact Contact Phan No.;(21110,334-0915 <br />Person; <br />MakelModet df Monitodng Sy'aom: VMDGR ROOT TLB 350 Data of T9eting/SerAcing; 9!41207:1 <br />R- Inventory of Eaulpmant TestadlCertltied <br />Chock tha aPVroPrI2t4 bOX09 to Indicates eche e h mom Inbovueurasr <br />Tarek ID: 87 <br />Tank ID. 91 <br />* in.Tank Gauging Probe. <br />Model; MAO 1 <br />9 h -Tank Gauping Prabo. <br />Model•, MAC 1 <br />* Annular Space or VaultSanaor. <br />Modal: 409 <br />8 Annular Space or VaultSeator. <br />Modal: 409 _ <br />® Pip" Sump I Trench Sensor(%), <br />Model: 20L <br />3 Piping Sump I Trench Son:or(s). <br />Model: 208 <br />* Ftll Sump Sen%or(a). <br />Model. 208 <br />19 FM Sump Sen5ar(s). <br />Modal! 208 <br />N Mechanical Utto Look Detector. <br />Model; P14 PETRO <br />X Mechanical Line Leak Dotoatar. <br />Model: fE PETRG <br />❑ Electronic Une Leek Detooreu, <br />Modol; <br />0 Electronic Una Leak Dotector. <br />Model: <br />❑ Tank Overfill / I-Ilgh-Level Sensor, <br />Model: <br />0 Tdnk Overfill I Hight -Level Sensor, <br />Model: <br />Q Othoe (:pacify equipment type and model in 5o011on E on Pago 2), <br />Otfor (speclry Dqulpment typo and modal In sottlon E on Page 2), <br />Tank 1D: 171E <br />Tank ID: 878Y ON <br />IS In -Tank Gauging Protea. <br />Mndal: MAO I <br />Z kh-Tark Gauping Probe. <br />Model; MAG 1 <br />R Annular Wee or VteiltSerc:er. <br />Model, 4oe _ <br />2 Annular Space or Vault Gontor. <br />Modal: 400 <br />19 Plpinq Sump / Traneh 3enaor(s), <br />Medoc: 208 <br />M Piping Sump! Trench Son sorts). <br />Model: 208 <br />2 FII Sump Sensor(%)• <br />Modef: 200 <br />C& P111 Su MP $Art or(s). <br />Model; 208 <br />R Mechanical Urn Leek Detector, <br />Model: LG 2000 <br />8 Mechanical tine LPMk flntnctor. <br />Modal: FE PETRO <br />C] R04mNe Line Look Detector. <br />Modd: <br />N Electronle Line Lank Dr+tattor. <br />MDdel; <br />Q Tank Overfill l High -Level Sensor. <br />Model: <br />❑ Tank Cvor011 / Hlgh-LAvel Sonsor. <br />MWAI: _ <br />❑ Other (Spoeq equipment typo and modal in Section E on Page 2). <br />❑ Other (opacify oqulpmenttype and modal In Section E on Pnga 2)• <br />Dlspensor ID; 1.2 <br />Dispenser ID: 3.4 <br />Ditipen%ar CwttAnmont Sonsor(s), <br />Model; 209 _ _ ___ <br />U Dispenser Containment Sontar(t). <br />Model; 208 <br />Shear Velve(a), <br />IS Shear Vefve(:). <br />❑ Of%penmr Containment Floet(s) and Chain(s), <br />❑ Dl%pentnr Containment Moot(r.) end Choln(s). <br />01sperisar ID, 54 <br />Dlsponser ID: 74 <br />N Dirponeor Containment Senson(s), <br />Model; 208 <br />8 Dispenser Contalrirnent Soneor(s), <br />Model, 208 <br />iFQ Sharer VaWa(s). <br />14 Sheer Valve(s). <br />❑ Dispenser Containment float(.) and Chain(t). <br />Q Dis. nsar Containment Float(q) and Chah(s). <br />DisponserID: 9.10 <br />Dlsponsa ID: 11-12 <br />10 Dispenser Contalnment <br />Dtapensat Comnintnont Sontor(s). <br />Mode(: 208 <br />sonsor(s). <br />Model: 206 <br />I� q henr VnlvP(%), <br />® Shear Valve(s). <br />C1 Dltinanser Containment noet(s) and Cbaln(s). <br />❑ Dlspenscr Containment Float(s) and Chaln(s). <br />'a tno mcmiry contnlns mora mnhm or ampon Sorel copy ❑Ds open, mauaW nrarmachon rnr aTory conn — uiaF-- nc .in .n..wy. <br />C. Cerp1jea0an • I certily that the equipment Identified In tht6 document was Inspectedfservlced )n accordance with the 0lanufacturem' <br />I'tuhte(lrles. Altaehed to" eerdtreatlan Is Information (e.g, manurAoturererchecidist%) necessaryto verify that this Inrormation Is correct <br />wW a Plot Plan shoWng the layout of rnonitoring egtdpment. For any equipment capatrfe of gerreraling such mporls, I tMve also attached a <br />copy or the report; 0 Gysb" Set-up ® Alarm htstoryroport <br />Tachnician Name (print); FELIX RAMIREZ Signature; -y <br />Certification Ne.: 534976 License No: 273934 -UT 09.1740 CTTL <br />sfn <br />Tag Company Nama: AFFORDA.TEST Phone No, 2gGg) 7440113 <br />To-,tinq Company Addre%a 410 2 STRE T CA SSM2 Date of T9stIhg/54rVi4ftig; 09.04.13 <br />eaartitermg system cermroatlon Pngo 1 of 4 2/21/07 <br />