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Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at httr)://www.waterboards.ca.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 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 m Facility Name: BP#6020 Bldg.No.: Site Address: 1711 E.Yosemite City: Manteca Zip: Facility Contact Person: Contact Phone No.:(_)_ Make/Model of Monitoring System: TLS 50 Date of Testing/Servlcing: 02 /20 / 2009 8. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment Ins acted/serviced: TanklD: 87 TanklD: 89 / In-Tank Gauging Probe. Model: / In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 409 / Annular Space or Vault Sensor. Model: 409 / Piping Sump/Trench Sensor(s). Model: e Piping Sump/Trench Sensor(s)- Model: / Fill Sump Sensor(s). Model: e Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: if Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: i Electronic Line Leak Detector. Model: / Tank Overfill/High-Level Sensor. Model: N Tank Overfill I High-Level Sensor. Model: Other(s cify equipment t e and model in Section E on Pa 2). Other(specify a ui ment type and model In Section E on Page 2). Tank ID: 91 Tank ID: In-Tank Gauging Probe. Model: In-Tank Gauging Probe. Model: Y Annular Space or Vault Sensor. Model: 409 i Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: i.l Piping Sump/Trench Sensor(s). Model: ,t Fill Sump Sensor(s). Model: i 1 Fill Sump Sensor(s). Model: / Mechanical Line Leak Detector. Model: U Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model I Electronic Line Leak Detector. Model: r Tank Overfill/High-Level Sensor. Model: Tank Overfill/High-Level Sensor. Model: Other(specify equipment t e and model in Section E on Pace 2). i Other(specify equipment type and model in Section E on Page 2), DispenserlD: 1&2 Dispenser LD: 7&8 X Dispenser Containment Sensor(s). Model: 323 X Dispenser Containment Sensor(s). Model: 323 X Shear Valve(s). X Shear Valve(s). Dispenser Containment Floats and Chain(s). u Dispenser Containment Floats and Chain(s), Dispenser lD: 3&4 DispenserlD: 9&10 X Dispenser Containment Sensor(s). Model: 323 X Dispenser Containment Sensor(s). Model:_323 X Shear Valve(s). X Shear Valve(s). Dispenser Containment Floats and Chaln s. N ii Dispenser Containment Floats and Chain(s). Dispenser ID: 5&6 Dispenser ID: 11&12 X Dispenser Containment Sensor(s). Model: 323 X Dispenser Containment Sensor(s). Model: 323 X Shear Valve(s). X Shear Valve(s), Dispenser Containment Floats and Chain(s). 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 Inspected/servlced 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): Aaron Shultz Signature: Cenilicarion No,: 5266795-UC License.No.: 902034 Testing Company Name: B&T Service Station Contractors Phone No.:f 805 1 929-8944 Testing Company Address: 630 S Frontage Rd Nipomo Ca 93444 Date of Testing/Servicing: 02 20/ 2009 Monitoring System Certification Page 1 of 4 12/07 1