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f4 0 Appendix V1 0 MONITORING SYSTEM CERTIFICATION 13ECEIVED 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 FEB 0 Regulations 0014 This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be preparedfiliNVIRONMENTAL HEAL:rfj each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system PER11 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. '10IT/SEWICES A. General Information Facility TRACY VALERO Site Aridrm%s- 2375 N. TRACY BLVD. Facility Contact Parson - Bldg. No.: Contact Phone No.: Zip: 95377 Make/Model of Monitoring System: VEEDER ROOT TLS -350 — Date of Testing/Servicing: 915/2013 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspect serviced: Tank ID: 87 Tank Size: Tank ID: Tank Size: 0 In -Tank Gauging Prole. Model: 0 In -Tank Gauging Probe. Model: 0 Annular Space or Vault Sensor. Model: 407 171 Annular Space or Vault Sensor. Model: 0 Piping Sump / Trench Sensor(s). Model: 0 Piping Sump / Trench Sensor(s). Model: 0 Fill Sump Sensor(s). Model: 0 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: 0 Tank Overfill / High -Level Sensor. Model: [I Other (specify equipment type and model in Section E onPage2). 0 Other (specify equipment type and model in Section E on Page 2). Tank ID: DIE Tank Size: Tank ID: 91 Tank Size: [I In -Tank Gauging Probe. Model: El In -Tank Gauging Probe. Model: 0 Annular Space or Vault Sensor. Model: 407 0 Annular Space or Vault Sensor. Model: 407 [3 Piping Sump / Trench Sensor(s). Model: 0 Piping Sump / Trench Sensor(s). Model: [3 Fill Sump Sensor(s). Model: 0 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: [3 Tank Overfill / High -Level Sensor. Model: 0 Tank Overfill / High -Level Sensor. Model: 0 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). Dispenser ID: Dispenser ID: [I Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model: [3 Shear Valve(s). 0 Shear Valve(s). E3 Dispenser Containment Float(s) and Chain(s). El Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: [3 Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model: [3 Shear Valve(s). 0 Shear Valve(s). 0 Dispenser Containment Float(s) and Chain(s). [3 Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment 0 Dispenser Containment Sensor(s). Model: Model: [3 ShearValve(s). El Shear Valve(s). [3 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 -1 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 akar apply): 0 System set-up 0 Alarm history report Technician Name (print): ZANE NIMMO Signature: Certification No.: A28446 — License No: 041676 Testing Company Name: AFFORDA-TEST Phone No. (209) 7440113 Testing Company Address: 416 ' GALT, LT, CA 95632 Date of Testing/Servicing: 9/5/13 Monitoring System Certification Page 1 of 4 2/21/07