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Appendix V1 MW a�� On MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California JUN 2, 1 Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations ENVIRONMENT HEALTH This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for PERMIT/SERME" 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 LIST systems within 30 days of test date. A. General Information Facility Name: MEL BOKIDES PETROLEUM Site Address: 444 MOSSDALE RD Facility Contact Person: Make/Model of Monitoring System: VEEDER ROOT TILS 350 Bldg. No.: City: LATHROP Contact Phone No.: ( B. Inventory of Equipment Tested/Certified Check the aoorooriate boxes to indicate sDecific eauiDment inspected/serviced: Zip: Date of Testing/Servicing: 05-18-10 Tank ID: 87 Tank ID: 91 • In -Tank Gauging Probe. Model: MAG2 0 In -Tank Gauging Probe. Model: MAG2 • Annular Space or Vault Sensor. Model: 420 0 Annular Space or Vault Sensor. Model: 420 SPLIT W 87/ DIE • Piping Sump / Trench Sensor(s). Model: 208 0 Piping Sump / Trench Sensor(s). Model: 208 • Fill Sump Sensor(s). Model: 0 Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: PE PETRO 0 Mechanical Line Leak Detector, Model: 0 Electronic Line Leak Detector. Model: 171 Electronic Line Leak Detector. Model: • Tank Overfill / High -Level Sensor. Model: 0 Tank Overfill / High -Level Sensor. Model: • Other (specify equipment type and model in Section E on Page 2). 0 Other (specify equipment type and model in Section E on Page 2). Tank ID: DIE Tank ID: 0 In -Tank Gauging Probe. Model: • In -Tank Gauging Probe. Model: MAG2 • Annular Space or Vault Sensor. Model: 420 SPLIT W 87191 171 Annular Space or Vault Sensor. Model: • Piping Sump / Trench Sensor(s). Model: 208 El Piping Sump / Trench Sensor(s). Model: El Fill Sump Sensor(s). Model: [I Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: 0 Tank Overfill / High -Level Sensor. Model: [I Tank Overfill / High -Level Sensor. Model: [I Other (specify equipment type and model in Section E on Page 2). [1 Other (specify equipment type and model in Section E on Page 2). Dispenser ID: 1-2 Dispenser ID: 3-4 • Dispenser Containment Sensor(s). Model: 208 0 Dispenser Containment Sensor(s). Model: 208 • Shear Valve(s). 0 Shear Valve(s). El Dispenser Containment Float(s) and Chain(s). [I Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5-6 Dispenser ID: 7-8 . • Dispenser Containment Sensor(s). Model: 208 0 Dispenser Containment Sensor(s). Model: 208 • Shear Valve(s). 0 Shear Valve(s). [I Dispenser Containment Float(s) and Chain(s). [I Dispenser Containment Float(s) and Chain(s)- Dispenser ID: 9-10 DispenserID: 11-12 0 Dispenser Containment * Dispenser Containment Sensor(s)- Model: 208 Sensor(s). Model: 208 * Shear Valve(s). Shear Valve(s). * Dispenser Containment Float(s) and Chain(s). E] 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): El System set-up 0 Alarm history report Technician Name (print): Signature: Certification No.: 5273934 -UT License No: 08-1740 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 Testing Company Address: 416 2" STREET GALT, CA 95632 _ Date ofTesting/Servicing: 05-18-10 Monitoring System Certification Page I of 4 1 2/21/07 S) r- C_ _t+