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RECoBVED .iu1J 0 1 2018 Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://,. "jW79t-rbwrds t a qov.) MONITORING SYSTEM CERTIFICATION �IhENT 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 owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information CRUISERS Facility Name: Bldg.No.: Site Address: 1137 W LATHROP City:_MANTECA_ Zip:_ Facility Contact Person:_MONICA Contact Phone No.._209 284-2760 Make/Model of Monitoring System:_VEEDER ROOT TLS 350 Date of Testing/Servicing:9/7/2017 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment ins ected/serviced: Tank ID T1 87 Tank ID:T2 91 X In-Tank Gauging Probe. Model:_VEEDER ROOT_ X In-Tank Gauging Probe. Model:_VEEDER ROOT_ X Annular Space or Vault Sensor. Model:_420 X Annular Space or Vault Sensor. Model:_420 X Piping Sump/Trench Sensor(s). Model:_208 X Piping Sump I Trench Sensor(s). Model:_208 X Fill Sump Sensor(s). Model:_208 X Fill Sump Sensor(s). Model: 208 Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector Model: X Electronic Line Leak Detector. Model:VEEDER ROOT X Electronic Line Leak Detector. Model:_VEEDER ROOT_ X Tank Overfill I High-Level Sensor. Model: VEEDER ROOTX Tank Overfill/High-Level Sensor, Model. VEEDER ROOT Other(specifyequipment a and model in Section E on Page 2_ Other(specify equipment t e and model in Sect_ion E on Pa 2). Tank ID:_T3 DIESEL Tank ID: X In-Tank Gauging Probe. Model:VEEDER ROOT_ In-Tank Gauging Probe. Model: X Annular Space or Vault Sensor. Model:_420 Annular Space or Vault Sensor. Model: X Piping Sump/Trench Sensor(s). Model:_208 Piping Sump/Trench Sensor(s). Model: X Fill Sump Sensor(s). Model:_208_ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: X Electronic Line Leak Detector. Model:VEEDER ROOT_ Electronic Line Leak Detector. Model: X Tank Overfill/High-Level Sensor. Model:_VEEDER ROOT_ Tank Overfill/High-Level Sensor. Model: Other(Specify equipment t e and model in Section E on Page 2). Other(specify equipment t e and model in Section E on Pa 2). Dispenser ID: 1/2 Dispenser ID: 3/4 X Dispenser Containment Sensor(s). Model.208_ X Dispenser Containment Sensor(s). Model:208 X Shear Valve(s). X Shear Valve(s). Dis enser Containment Floats and Chain(s). Dispenser Containment Floats and Chain(s). Dispenser ID: 5/6 Dispenser ID: 7/8 X Dispenser Containment Sensor(s). Model:208_ X Dispenser Containment Sensor(s). Model:208 X Shear Valve(s). X Shear Valve(s). Dispenser Containment Floats and Chains Dispenser Containment Floats and Chain(s). Dispenser ID:_9110 Dispenser ID:_11/12 X Dispenser Containment Sensor(s). Model:_208 X Dispenser Containment Sensor(s). Model:_208 X Shear Valve(s). Shear Valve(s). Dispenser Containment Floats and Chains Dis enser Containment Floats and Chain(s). 'If the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility. C. Certification - I certify that the equipment identified in this document was inspectediserviced 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 capable of generating such reports,I have also attached a copy of the report;(check all that apply: System set-up Alarm history report Technician Name(print):PETER HUKE Signature: Certification No.: A25510 License.No.: Testing Company Name: LC SERVICES Phone No.:L559_)_444 1730 Testing Company Address:3887 N VALENTINE,FRESNO 93722 Date of Testing/Servicing:9/7_/2017 Monitoring System Certification Page 1 of 4 12107 1 2/21/07