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Appendix VI 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 ownerioperator. 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: TRACY VALERO Bldg. No.: Site Address: 2375 TRACY BLVD City: TRACY Zip: Facility Contact Person: HAKAM Contact Phone No.: (209) 835-5358 Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 10-07-13 B. inventory of Equipment Tested/Cert€fied Check the approoriate boxes to indicate s ecifl a ui ment ins ad/serviced: TanklD: 87 TanklD: 89 I@ in -Tank Gauging Probe. Model: MAG ® In -Tank Gauging Probe. Model: MAG ® Annular Space or Vault Sensor. Model: 407 ® Annular Space or Vault Sensor. Model: 407 ® Piping Sump / Trench Sensor(s). Model: 208 ® Piping Sump / Trench Sensor(s), Model: 208 ❑ Fill Sump Sansor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: LD 2000 M Mechanical Line Leak Detector. Model: LD 2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: FLAPPER 0 Tank Overfill / High -Level Sensor. Model: FLAPPER ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: 91 Tank ID: WASTE Ott» ® In -Tank Gauging Probe. Model MAG ❑ in -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor, Model: 407 ® Annular Space or Vault Sensor. Model: 407 ® Piping Sump /Trench Sensor(s). Model: 208 N Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sansor(s). Model: 0 Mechanical Line Leak Detector. Model: LD 2000 ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ID Tank Overfill / High -Level Sensor. Model: FLAPPER ❑ Tank Overfill / High -Level Sensor. Model: ❑ 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 to Dispenser Containment Sensor(s). Model: 332 ® Dispenser Containment Sensor(s). Model; 332 0 Shear Valve(s). 0 ShearValve(s). ❑ Dispenser Containment Fiost(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 3.4 Dispenser ID: 5-6 ® Dispenser Containment Sensor(s). Model: 332 ® Dispenser Containment Sensor(s), Model: 332 ® Shear Valve(s). 0 Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser D: ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: Sensor(s). Model: ❑ ShearValve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ 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 Piot 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): 0 system set-up ® Alarm history report Technician Name (print): FELIX RAMIREZ Signature: e -._z, Certification No.: 5273934 -UT_ -_.- License No; 08-1740 Na _...... _..... ___._._._._....._._...._.._.- ___.._....._.—_..._ ............._.... _..... Testing Company me: ....... AFFORDA-TEST Phone No. (209) 744-0113_.__—__.._._.._ Testing Company Address: 416 STREET GALT,. CA 95632 _,-..,..— Date of Testing/Servicing: .1A-47-43 ................. Monitoring System Certification Page 1 of 4 2/21/07