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E MAR 2 7 2015 AppendLK V1 ENVIRONMENTAL HEALTH (Copies of Monitoring System Certification form and LIST Monitoring Plot Plan available at htt ://www.watft aff9imS MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Wft-IcLMA-State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division Regulations Title 23, California Code of 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 LIST systems within 30 days of test date. A. General Information Bldg. No.: Facility Name: SINCLAIR Site Address: 1001E )M ITE City: . MANTECA_ — Zip: 96336 Facility Contact Person: tLMNDER,— Contact Phone No.: ( 209 1 824-3898 Make/Model of Monitoring System: Date of Testing/Servicing: 02 / 26 2016 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific nulpE!ent ins serviced: Tank IM TANK I REG. • In -Tank Gauging Probe. Model: MAG I • Annular Space or Vault Sensor. Model: 409 I@ Piping Sump / Trench Sensor(s). Model: 208 El Fill Sump Sensor(s). Model: - N Mechanical Line Leak Detector. Model: VMI LD2000 o Electronic Line Leak Detector. Model: 0 Tank Overfill I Hililh-Level-$enser- Model: FLAPPER VALVE o Other (specify equipment type and model in Section E on P Tank 10: TANK 2 P - • In -Tank Gauging Probe. Model: MAG I • Annular Space or Vault Sensor. Model: 409 • Piping Sump / Trench Sensor(s). Model: 208 0 Fill Sump Sensor(s). Model: N Mechanical Line Leak Detector. Model: VMl L 11 Electronic Line Leak Detector. Model: 0 Tank Overfill / ser. Model: FLAPPER VALVE 0 Other (specify equipment type and model in Section E on Page 2). Dispenser ID: 0 Dispenser Containment Sensor(s).Model: 0 Shear Valve(s). Dispenser ID: 3 & 4 ti Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). Dispenser ID: 6 & 6 o Dispenser Containment Sensor(s). Model: g Shear Valve(s). Tank 10: TANK a DIESEL • In -Tank Gauging Probe. Model: -M&G I • Annular Space or Vault Sensor. Model: 409 • Piping Sump /Trench Sensor(s). Model: 208 u Fill Sump Sensor(s). Model: - Z Mechanical Line Leak Detector. Model: VM1 LD2000 0 Electronic Line Leak Detector. Model: 0 Tank Overfill/ Model: FLAPPER_ VALVE m, Other (sDecffv equipment type and model in Section E on Page ?). Tank ID: c In -Tank Gauging Probe. Model: o Annular Space or Vault Sensor. Model: o Piping Sump / Trench Sensor(s). Model: 0 Fill Sump Sensor(s). Model: o Mechanical Line Leak Detector. Model: C. Electronic Line Leak Detector. Model: , I Tank Overfill / High -Level Sensor. Model: 0 Other (specify equipment type and model in Section E on Page 2). Dispenser ID: . 7 j 8 0 Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). Dispenser Containment Flogs) and Chain(s). Dispenser ID: 0 Dispenser Containment Sensor(s). Model: 11 Shear Valve(s). r, Dispenser Containment Float(s) and Chaln(s). Dispenser ID: o Dispenser Containment Sensor(s). Model: o Shear Vatve(s). m, nimprinar 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 ins /serviced In accordance with the manufacturers' guidelines. Attached to this Certification is Information (e.g. manufacturers' checklists) necessary to VO4 that this Information Is correct and a Plot Plan showing the layout of monitoring any reuipment. For a 9quipment capable of gen ng h reports, I have also attached a �_ copy of the port; (check all that apply): =tarn set-up 'ZtjQarm history reportA/ Technician Name (print): GREG MSER Signature: Certification No.: A2I983 - License. No.: Testing company Name: KAISER COMMERCIAL PETROLEUM Testing Company Address: p. 0. BOX 1058, LINDEN, CA 95216 Monitoring system co"cation No.: 209 ) 887-2639 a of Testing/Servicing: 26 aQj§ Ml� 2/21/07