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1Y ry 0 Appendix VI RECEIVED 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 RFejaagorhe? 0 14 This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared fcENVIRONMENTAL 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. HEALTH DEPARTMENT 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 -SM MaketModel of Monitoring System: VEEDER ROOT TILS 350 Date of Testing/Servicing: 10-07-13 B. Inventory of Equipment Tested/Certified Check the aEproerlate boxes to indicate specific !Suipment inspected/serviced: ID: 87 Tank ID: 89 0 in -Tank Gouging Probe. Model: MAG I [9 In -Tank Gauging Probe. Model: MAG ,1Tank .0 Annular Space or Vault Sensor. Model: 407 0 Annular Space or Vault Sensor. Model: 407 0 Piping Sump / Trench Sensor(s). Model: 208 0 Piping Sump / Trench Sensor(s). -Model: 208 [3 Fill Sump Sensor(s). Model: Q Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: LID 2000 Mechanical Line Leak Detector. Model: -LD 2000 [3 Electronic Line Leak Detector, Model: ❑ Electronic Line Leak Detector. Model: 0 Tank Overfill / High -Level Sensor. Model: FLAPPER Tank Overfill / High -Level Sensor. Model: FLAPPER [3 Other (specify equipment type and model in Section E on Page 2). [3 Other (specify equipment type and model in Section E on Page 2). Tank ID: 91 Tank ID: WASTE OIL 19 In -Tank Gauging Probe. Model: MAG [I In -Tank Gauging Probe. Model: 0 Annular Space or Vault Sensor. Model: 407 0 Annular Space or Vault Sensor. Model: 407 0 Piping Sump / Trench Sensor(s). Model: 208 0 Piping Sump / Trench Sensor(s). Model: [3 Fill Sump Sensor(s). Model: [3 Fill Sump Sensor(s). Model: 0 mechanical Line Leak Detector. Model: LD 2000 El Mechanical Line Leak Detector. Model: [3 Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: 0 Tank Overfill I High -Level Sensor. Model: FLAPPER [3 Tank Overfill / High -Level Sensor. Model: 0 Other (specify equipment type and model in Section E on Page 2). 171 Other (specify equipment type and model in Section E on Page 2). Dispenser ID: 1-2 Dispenser ID: 3-4 IM Dispenser Containment Sensor(i). Model: 332 0 Dispenser Containment Sensor(s). Model: 332 0 Shear Valve(s). 0 Shear Valve(s). [I Dispenser Containment Float(s) and Chain(s). EI Dispenser Containment Float(s) and Chain(s). Dispenser ID: 3-4 Dispenser ID: 6-6 J@ Dispenser Containment Sensor(s). Model: 332 0 Dispenser Containment Sensor(s). Model: 332 CM Shear Valve(s). 0 Shear Valve(s). 13 Dispenser Containment Float(s) and Chain(s). [I Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment [3 Dispenser Containment Sensor(s). Model: Sensor(s). Model: 0 Shear Valve(s). ❑ Shear Valve(s). [3 Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). *lf 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): System set-up 0 Alarm history report Technician Name (print): FELIX RAMIREZ Signature: Certification No.: 6273934 -UT License No: 08-1740 Testing Company Name: AFFORDA-TEST Phone No. (209) 744 0113 Testing Company Address: 416 2m STREET GALT, CA 95632 Date of Testing/Servicing: 10-07-13 Monitoring System Certification Page 1 of 4 2/21/07