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Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at httDj/www.waterboards.cagov.) MONITORING SYSTEM CERTIFICATION For Use By All Junsdictions 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 forth 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 Facility Name: 76 Express Bldg.No.: Site Address. 419 S Main City. Manteca Zip_ 95366 Facility Contact Person: Bobby Contact Phone No. 209 39-7978 MakelModel of Monitoring System. Veeder-Root TLS-350 Date of TestinglServicing:_1�1 5128/2010 B. Inventory of Equipment Tested/Certified Check the apgropriate boxes to indicates ific ui t Ins ctedlserviced: Tank ID: 1 " 9 1Tank ID: 2- ,r In-Tank Gauging Probe. Model: < In Tank Gauging Probe. Model: x Annular Space or Vault Sensor. Model: 420 x Annular Space or Vault Sensor. Model: 420 % piping Sump I Trench Sensor(s)- Modek 208 K Piping Sump I Trench Sere"(s). Model 208 Fill Sump Sensor(s). Model Fin Sump Sensogs). Motet x Mechanical Line Leak Detector. Model: x Mechanical Lire Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill t High-Level Sensor, Model: I Tank Overfill/High-Level Sensor. Model: Other�! 22uipment and model in Section E on Page 2). 1 I Other equipment type and model in Section E on Paq e 2). Tank ID: .5-Ulesei Tank ID: x In-Tank Gauging Probe. Model: l In Tank Gauging Probe. Model: x Annular Space or vault Sensor. Model: 420 1' Annular Space or Vault Sensor. Model: x Piping Sump/Trench Sensor(s). Model: 208 i Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: i t Fill Sump Sensor(s). Model: x Mechanical Line Leak Detector. Model. 0 Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: :! Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: ;I Tank Overfill/High-Level Sensor. Model: Other(specify ui ment a and model in Section E on Paae Z, r. OtherLseuj2Ment a and model in Secticn E on DispenserlD: T72 DispenserlD: 3/4 x Dispenser Containment Sensor(s). Model:ZU5 1.1 Dispenser Containment Sensor(s). Model: x Shear Valve(s). x Shear Valve(s). D' eraser Containment Float(sj and Chain(s). n Dzpenser Containment Floats and Chain(s). Dispenser ID: Dispenser 10: ! Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: I Shear Valve(s). Shear Valve(s). DisDenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chains. Dispenser ID: Dispenser ID: Dispenser Containment Sensor(s). Model. Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Vaive(s). Disp2nser Containment goats and Chan s I. Dispenser 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'checkl-rsts)necessary to verify that this information is correct and a Piot 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): )r(System set-upAttarm history repoft� Technician Name(print): Call Wayne Henderson Signature: C' .? —- N/ Certification No.: ICC# 5252923-UT License.No.: CSLB# 856711 Testing Company Name: Henderson Maintenance Company Phone No.: 2l 09) 467-7573 Testing Company Address:PO Box 31325 Stockton, CA 95213 Date of TestinglServicing:_/_1 5/28/2010 Monitoring System Certification Page 1 of 4 12107 1 2/21/07