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0 RECEIVED Appendix vi JAN 3 1 2011 (Copies of Monitoring System Certification form and UST Monitoring Piot Pian available at j MONITORING SYSTEM CERTIFICATION EWRONMENTAL For Use By Ail Jurisdictions Within the State of California PERMIT/SlERMES Authority Cited:Chapter 6.7,Health and Safety Codes 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 Inform aii4n Facility Name: Valero Bldg.No.: Site Address: 1001 Main St City: Manteca Zip: 95336 Facility Contact Person: Contact Phone No.:(�) Make/Model of Monitoring System: BMC Date of Testing/Servicing:_/ / 1-28-11 B. Inventory of Equipment Tested/Certified Check the jpgLopriate—boxes to indicate speci—fic—equipment insl octedleerviced: FTank - Tank ID: - nk Gauging Probe. Model- x InTank Gauging Probe. Model vrlar Space or Vault Sensor. Model: x Annular Space or Vault Sensor. Model:409g Sump/Trench Sensor(s). Model: x Piping Sum/Trench Sensor(s). Model: 208um Sensor(s). Model: Fid Sum Sensor(s). Model:anical tine Leak Detector. Model: -W-200x Mechanical Line Leak Detector, Model: - Electronic Line Leak Detector. Model: Electronic Line Leak Detector. I: Tank Overfill/High-Level Sensor. Model: Tank Overfill/High-Level Sensor. Model: Other 040 equipment Noe-and model in Section E on P .2). Other(specify 2guW= and model ip S n E 2n P e . Tank ID: Ljieset Tank ID: x in-Tank Gauging Probe, Model:VR In Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: x Piping Sum/Trench Sensor(s). Model: 208 Piping Sump/Trench Sensor(s). Model: Fill Sum Sensor(s). Model: Fill Sump Sensor(s). Model: x Mechanical Line Leak Detector. Model - Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: Tank Overfill/High-Level Sensor. Model: Other i eM anjaggI i ecticn E on 2. Other= ui ang MSW in Section E onfage Z. Dispenser ID: Dispenser to: 414 Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: x Shear Valve(s). x Shear Valve(s). s. x neer Containment Fkoa4 a d Ch ins. x n nt Float(s) and Chale s. Dispenser 10: 010 Dispenser 10: 110 Dispenser Containment Sensor(s). Model: DispenserContainmmnt Sensor(s). Model: it ShearValve(s). x ShearValve(s). x -Dispenser Contai=21 OWN)and 2WInW. xDimmser ContainmentFloat(s)and Chain(s). Dispenser ID: Dispenser ID: Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model. Shear Valve(s). Shear Valve(s). Dispenser Containment Flost s and Cha' s Dispenser Containment Floats and Chem 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'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 at►that apply): System set-up Alarm jhIstory re ort Technician Name(print):Gavin Williams Signature: Certification No.: ICC# 8016288-UT License.No.:CSLB# 856711 Testing Company Name, Henderson Maintenance Company Phone No.: 2t 09 ) 467-7573 Testing Company Address:PO Box 31325 Stockton, CA 95213 Date of Testing/Servicing:_/�! 1-28-11 Monitoring System Certification Page 1 of 4 12107 1 2/21/07