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0 Appendix V1 0 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 61@4402 0 1 4 This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be pared for each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to � owner/operator. The ownerloperator must submit a copy of this form to the local agency regulating LIST systems within 30 MENTAL must A. General Information Facility Name: TRACY VALERO Bldg. No.: Site Address: Facility Contact Person: 2376 TRACY BLVD City: TRACY Zip: HAKAM Contact Phone No.: (2 09) 335-5368 Make[Model of Monitoring System: VEEDER ROOT TLS 350 I. Inventory of Equipment Tested/Cortified Date of Testing/Servicing: 10-11-13 1f the facility contains more tanks or dispensers, copy this form. Include information for every Wk and dispenser at the lad Ity. 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): 0 System set-up 0 Alarm history report Technician Name (print): FELIX RAMIREZ Signature: Certification No.: 5273934 -UT License No: 08-1740 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 Testing Company Address: 416 20 STREET GALT, CA 95632 Date of Testing/Servicing: 10-11-13 Monitoring System Certification Page 1 of 4 2/21/07 Tank ID: 87 Tank ID: 89 • In -Tank Gauging Probe. Model: MAG 0 In -Tank Gauging Probe. Model: MAG • Annular Space or Vault Sensor. Model: 407 0 Annular Space or Vault Sensor. Model: 407 • Piping Sump / Trench Sensor(s). Model: 208 0 Piping Sump / Trench Sensor(s). Model: 208 E] Fill Sump Sensor(s). Model: E3 Fill Sump Sensor(s). Model: I@ Mechanical Line Leak Detector. Model: LD 2000 0 Mechanical Line Leak Detector. Model: LD 2000 [I Electronic Line Leak Detector. Model: El Electronic Line Leak Detector. Model: 0 Tank Overfill / High -Level Sensor. Model: FLAPPER - Z Tank Overfill I High -Level Sensor. Model: FLAPPER [I 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 j Tank ID: WASTE OIL I 0 In -Tank Gauging Probe. Model: - 0 In -Tank Gauging Probe. Model: MAG j@ Annular Space or Vault Sensor. Model: 407 9 Annular Space or Vault Sensor. Model: 407 0 Piping Sump / Trench Sensor(s). Model: 208 I 0 Piping Sump / Trench Sensor(s). Model: C3 Fill Sump Sensor(s). Model: 0 Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: LID 2000 0 Mechanical Line Leak Detector. Model: Ej Electronic Line Leak Detector. Model: 0 Electron;c Line Leak Detector. Model: 0 Tank Overfill / High -Level Sensor. Model: FLAPPER [I Tank Overfill / High -Level Sensor. Model: [3 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: 1-2 Dispenser ID: 3-4 • Dispenser Containment Sensor(s). Model: 332 0 Dispenser Containment Sensoqs). Model: 332 • Shear Valve(s). 0 Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). 0 Dispenser Containment Float(s) and Chain(s). Dispenser ID: 3-4 FlDlsp;nser ID: 6-6 • Dispenser Containment Sensor(s). Model: 332 Z Dispenser Containment Sensor(s). Model: 332 • Shear Valve(s). 0 Shear Valve(s). [I Dispenser Containment Float(s) and Chain(s). 0 Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: [3 Dispenser Containment [3 Dispenser Containment Sensor(s). Model: Sensor(s). Model: [3 Shear Valve(s). ❑ Shear Valve(s). El Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). I 1f the facility contains more tanks or dispensers, copy this form. Include information for every Wk and dispenser at the lad Ity. 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): 0 System set-up 0 Alarm history report Technician Name (print): FELIX RAMIREZ Signature: Certification No.: 5273934 -UT License No: 08-1740 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 Testing Company Address: 416 20 STREET GALT, CA 95632 Date of Testing/Servicing: 10-11-13 Monitoring System Certification Page 1 of 4 2/21/07