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i Appendix VI i (Copies of Monitoring System Certification form and UST Monitoring Plat Plan avallable at http://www.waterboards.0a.gov.) MONITORING SYSTEM CERTIFICATION 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 I Rogulations I 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 CREASERS Facility Name: Bldg.No.: Sila Address: 1137 W LATHROP City:TM,_MANTECA_ Zip: Facltity Contact Person:_MONICA Contact Phone No.:_209 284-2760 I I MakelModel of Monitoring System:_VEEDER ROOT TLS 350 Dale of Tesling/Servicing:9f712017 i B. Inventory of Equipment Tested/Certified Check the approerlate boxes to Indicatespecific a ul rent fns acted/serviced: Tank ID Ti 87 Tank ID:T2 91 X In-Tank Gauging Probe. Model:_VEEDER ROOT_ X In-Tank Gauging Probe. Model: VEEDER ROOT_ j X Annular Space or Vault Sensor. Model:_420 X Annular Space or Vault Sensor. Model:—420 ; X Plping Sump l Trench Sensor(s). Model:_208 X Piping Sump/Trench Sensor(s). Model:"208 I X F41 Evmp Sensor(s). Model:_208 X FIII Sump Sensor(s). Model: 208_ 3 Mechanical Line Leak Detector. Model:_ Mechanical Line Leak Detector Model: i X Electronic Line Leak Detector. Model:VEEDER ROOT X Electronic Line Leak Detector. Model; VEEDER ROOT_ i X Tank Overfill/High-Level Sensor. Model: VEEDER ROOT` X Tank Overfill/High-Level Sensor Model:^_VEEDER ROOT U Other(specify a of ment 1 e and model In Section E on_P_a e 2. i, Other(specifyequipment I e and model in Section E on Page 2). Tank ID:_T3 DIESEL Tank ID: i X In-Tank Gauging Probe. Model:VEEDER ROOT_ U In-Tank Gauging Probe, Model: i X Annular Space or Vault Sensor. Model: 420 U Annular Space or Vault Sensor. Model: X Piping Sump t Trench Sensor(s). Model:,�-,208 o Piping Sump/Trench Sensor(s). Model: X FIII Sump Sensor(s). Model: 208_ i i FIII Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: +; Mechanical Line Leak Detector. Model: X EleciroOc Line Leak Detector. Model:VEEDER ROOTU Electronic Line Leak Detector. Model: X Tank Overfill/Hlgh-Level Sensor, Model:_VEEDER ROOT__ i i Tank Overfill/High-Level Sensor. Model: i D Other(specify equipment 1 e and model in Section E on Page 7.. C Other(specify equipmentliatand model in Section E on Page 2)- Dispenser ID. 112J Dispenser ID: 3/4 I X Dispenser Containment Sensogs). Model:208_ X Dispenser Containment Sensor(s). Model:208 j X Shear Valve(s). X Shear Valve(s), i Dispenser Containment Floats and Chain(s). Dispenser Containment Floats and Chaln s. i DlspenserID: 516 Dispenser ID: 718 X Dispenser Containment Sensor(s), Model:208_ X Dispenser Containment Sensor(s), Model:208 X Shear Valve(s). X Shear Valve(s). D Dispenser Containment Floats and Chaln s. C Dls enser Containment Floats and Chaln s. Dispenser ID:_9110 Dispenser ID:_11112 X Dispenser Containment Sensor(s). Model:_208 X Dispenser Containment Sensor(s). Model:_208 X Shear Velve(s), ii Shear Vatve(s). D Dis enser Containment Floats and Chains n Dispenser Containment Floats and Chaln 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 Inspectediservlced 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 o Alarm history report 1 Technician Name(print):PETER HUKE Signature: � Cert�caliJn No.:_A26510 License.No.: I Testing Company Name: LC SERVICES Phone No.:L559_,.,)_,444 1730 Testing Company Address:3887 N VALENTINE,FRESNO 93722 Date of TestinglServicing:917 /2017_ iI Monitoring System Certification Page 1 of 4 12107 j I l 2/21/07 1