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u 9 - -LL�:�4L.�)11116.-L- Appendix VI JUL 2 5 2016 (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at.http://www.waterboards.ca.,Qov.) 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 owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. Generallnformation Facility Name: Kaiser Manteca Bldg. No.: Site Address: 1777 W. Yosemite Avenue City: Manteca Facility Contact Person: Sam Corbin Contact Phone No.: Zip: 95337 Make/Model of Monitoring System: Veeder Root - TLS 350 Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the aooroorfate boxes to Indicate soecific eauioment Insoected/serviced: 7/8/2016 Tank ID: T1 Diesel Tank AST Tank ID: T2 UST Diesel sZ V a/ In -Tank Gauging Probe. Annular Space or Vault Sensor. Piping Sump / Trench Sensor(s). Fill Sump Sensor(s). Mechanical Line Leak Detector. Model Model: Model: 794380-208 Model: 794380-208 Model: N d In -Tank Gauging Probe. Anular Space or Vault Sensor. Piping Sump / Trench Sensor(s). Fill Sump Sensor(s). Mechanical Line Leak Detector. u Model: 794380-303 Model: Model: Model: Electronic Line Leak Detector. Tank Overfill / High -Level Sensor. Model: Model: MAG Pius St Electronic Line Leak Detector. Tank Overfill / High -Level Sensor. Model: Model: MAG Pius El Other (specify equipMent ty22 and model in Section E on Page 2). Other (specify equipment t e and model in Section E on Page 2. Tank ID: Tank ID: In -Tank Gauging Probe. Annular Space or Vault Sensor. Piping Sump / Trench Sensor(s). Fill Sump Sensor(s). Mechanical Line Leak Detector. Model: Model: Model: Model: Model: In -Tank Gauging Probe. Annular Space or Vauft Sensor. Piping Sump / Trench Sensor(s). FII Sump Sensor(s). Mechanical Line Leak Detector. Model: Model: Model: Model: Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Others cif a ui ment tX22 and model Model: in Section E on Pa e 2 . Tank Overfill / High -Level Sensor. Model: Other (specify a ui ient tyge and model in Section E on Pae 2 . Dispenser ID: Dispenser Containment Sensor(s). Model: Shear Valve(s). penser ID: Dispenser Containment Sensor(s). Model: _ Shear Valve(s). Dis enser Containment Floats and Chains .A Dispenser Containment Floats and Chains . Dispenser ID: Dispenser Containment Sensor(s). Shear Valve(s). Model: DispenseriD: Dispenser Containment Sensor(s). Model: Shear Valve(s). Dispenser Containment Float(s and Chain(s). Dis enser Containment Floats and Chain(s). Dispenser ID: Dispenser Containment Sensor(s). Shear Valve(s). Model: Dispenser ID: Dispenser Containment Sensor(s). Model: Shear Valve(s). H �J Dispenser Containment Floats and Chain(s Dis enser Containment Floats and Chains . -if tie taciisty contains more tanks or a ispensers, copy mss tome. incivas vTomiation Tor every tank aria aispenser at me TacilKy. 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): e/ System set-up W Alarm history report Tedinician Name (print): David Walker Signature: _ _ _ _ __. _ .. Certification No.: A32030 License. No.: 808313 Testing Company Name: Belshire Environmental Services, Inc. Phone No. Testing Company Address: 25971 Towne Centre Dr., Foothill Ranch, CA 92610 949 %460-5200 Date of Testing/Servicing: 7/8/2016 Monitoring System Certification Page 1 of 4 12107