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!E(;LiVtD Appendix V1 (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at hftp://www.swrcb.ca.gov.�A�l MONITORING SYSTEM CERTIFICATION For Use All Jurisdictions Within the State of California 0 Authority Cited.,Chapter 6.7,Health and Safety Code;Chapter 16,Division 3, Title 23,California codiF6f-'' 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: CHEVRON#99840 Bldg.No.: Site Address: 4344 E WATERLOO RD@ 99 City: STOCKTON Zip: 95215 Facility Contact Person: MANAGER Contact Phone No.: 209-931-2186 Make/Model of Monitoring System: Veeder Root TLS-350 Date of Testing/Servicing: 12/29/2015 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment ins serviced: Tank ID: T1-SUPREME Tank ID: T2-REG UNLEAD W In-Tank Gauging Probe. Model: mag 8473 rwo in-Tank Gauging Probe. Model: mag 8473 W Annular space or Vault Sensor. Model: 409 F70 Annular space or Vault Sensor. Model: 409 P Piping Sump/Trench Sensor(s). Model: 208 W Piping Sump/Trench Sensor(s). Model: 208 r Fill Sump Sensor(s). Model: r— Fill Sump Sensor(s). Model: r Mechanical Line Leak Detector. Model: r Mechanical Line Leak Detector. Model: rV Electronic Line Leak Detector. Model: Veeder Root PLLD rvO Electronic Line Leak Detector. Model: Veeder Root PLUD Tank Overfill/High-Level Sensor.Model: flapper rvo Tank Overfill/High-Level Sensor.Model: flapper Other(specify equipment type and model in Section E on PacieT_. r—Other(specify equipment type and model in Section E on Page 2). Tank ID: Tank ID: r In-Tank Gauging Probe. Model: r In-Tank Gauging Probe. Model: r Annular Space or Vault Sensor. Model: r Annular Space or Vault Sensor. Model: r Piping Sump/Trench Sensor(s). Model: r Piping Sump/Trench Sensor(s). Model: r Fill Sump Sensor(s). Model: r Fill Sump Sensor(s). Model: r— Mechanical Line Leak Detector. Model: r— Mechanical Line Leak Detector. Model: r Electronic Line Leak Detector. Model: r Electronic Line Leak Detector. Model: r Tank Overfill if High-Level Sensor.Model: r—Tank Overfill/High-Level Sensor.Model: r Other(seecify equipment type and model in Section E on Page r—Other(specify equipment type and model in Section E on Facie 2). Dispenser 1/2 Dispenser 3/4 ID: ID: W Dispenser Containment Sensor(s).Model: 208 rV Dispenser Containment Sensor(s).Model: 208 P Shear Valve(s). rv-0 Shear Valve(s). r Dispenser Containment Float(s)and Chain(s). r Dispenser Containment Float(s)and Chain(s). Dispenser 5/6 Dispenser 7/8 ID: ID: r%O Dispenser Containment Sensor(s).Model: 208 rW Dispenser Containment Sensor(s).Model: 208 rV Shear Valve(s). R Shear Valve(s). r Dispenser Containment Float(s)and Chain(s). r Dispenser Containment Float(s)and Chain(s). Dispenser 9/10 Dispenser 11/12 ID: ID: rvO Dispenser Containment Sensor(s).Model: 208 ryO Dispenser Containment Sensor(s).Model: 208 R Shear Valve(s). P Shear Valve(s). r Dispenser Containment Float(s)and Chain(s). I r 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).P System set- up P Alarm history report Technician Name(print): Brent Bowen Signature: Certification No.: 842815 License.No.: 743160 Class'A' Testing Company Name: Tanknology Phone No.: (800)800-4633 Testing Company Address: 11000 N.MoPac Expressway Suite 500 Date of Testing/Servicing: 12/29/2015 Monitoring System Certification Page 1 of 3 12/07