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Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://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 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-350 Date of Testing/Servicing: 02 /20 / 2009 B Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment ins ected/serviced: Tank ID: 87 Tank ID: 89 In-Tank Gauging Probe. Modgi. In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. odel: 409 Annular Space or Vault Sensor. Model: 40 Piping Sump/Trench Sen Model Plping Sump/Trench Sensor(s). Nil Fill Sump Sensors Model: I I Fill Sump Sensor(s). Model: Mecfranic eak Detector. Model: I I Mechanical Line Lea or. Model: Ele c Line Leak Detector. Model 0 Electronic Li Detector. Model: ank Overfill/High-Level Sensor. Model: Tan ill/High-Level Sensor. Model: Others cit equipment t e and model in Section E on Page 2). er(specify equipment t e and model in Section E on Pae 2). Tank ID: 91 Tank ID: In-Tank Gauging Probe. Model: I I In-Tank Gauging Probe. Model: -_ Annular Space or Vault Sensor. M I I Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor s odel: u Piping Sump/Trench Sensor(s). Model: Fill Surnp Sensor Model Fill Sump Sensor(s). Model: Mechanic eak Detector. Model: Mechanical Line Leak Detector. Model; El is Line Leak Detector. Model; I Electronic Line Leak Detector. Model: 07-an k Overfill/High-Level Sensor. Model: I Tank Overfill/High Level Sensor. Model: Other(specify equipment t e and model in Section E on Pae 2). Other(specify equipment type and model in Section E on Page 2). Dispenser ID: 13& 14 Dispenser ID: X Dispenser Containment Sensor(s). Model: 323 Dispenser Containment Sensor(s). Model: X Shear Valve(s). Shear Valve(s). Dispenser Containment Floats and Chaln s). Dispenser Containment Floats and Chain(s). Dispenser ID: _ 15&16 Dispenser 10: X Dispenser Contalnment Sensor(s). Model:_323 Dispenser Containment Sensor(s). Model: X Shear Valve(s). Shear Valve(s). I Dispenser Containment Floats and Chain(s). Dispenser Containment Floats and Chain(s). Dispenser ID: Dispenser ID: Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: Shoar Valve(s). I i Shear Valve(s). 31 Dispenser Gontalnment Floats and Chaln s. u Dispenser Containment Float(s)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/serviced 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): �I System set-up Alarm history report 1 echnician Name(print): Aaron Shultz Signature: _ Certification No.: 5266795-UC License.No.: 902034 Testing Company Name: B&T Service Station Contractors Phone No.-( 805 ) 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