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Appendix VI RECEWED (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.watettaparcts.aa.QRy MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California 11RO i M N TAA Authority Cited:Chapter 6.7, Health and Safety Code; Chapter 16,Division 3, Title 23, AENT 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. General Information Facility Name: Kaiser Stockton Bldg.No.: Site Address: 7373 West Lane City:Stockton Zip: 95210 Facility Contact Person: Darryl Gardner Contact Phone No.:(� Make/Model of Monitoring System: Veeder Root-TLS 350 Date of Testing/Servicing: 6/28/2018 B. Inventory of Equipment Tested/Certified Check thea ro riate boxes to indicates ecific a ui ment Inspected/serviced: Tank ID: T1 DSL Tank ID: In-Tank Gauging Probe. Model: us In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor.. Model: V Piping Sump/Trench Sensor(s). Model:794380-208 Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s)_ Model: FII Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: +� Tank Overfill/High-Level Sensor. Model:Flapper Tank Overfill/High-Level Sensor. Model: Other(specify equipment t and model In Sectlon E on Page 2). Ity equipment a and model in Section E on Page 2). TanklD: TanklD: In-Tank Gauging Probe. Model: In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: FII Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector, Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: Tank Overfill/High-Level Sensor. Model: Other LsLec!fX equi2jent tX22 and model in Section E on Page 2). Other(s2ecifX e2ulement!yee and model in Section Dispenser ID: spenserlD: 8 Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). Dispenser Containment Float(sj and Chains. I Dis enser Containment Floats and Chain(s). Dispenser ID: Dispenser iD: 8 Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chaln(s). L penser ID: Dispenser ID: Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). Dis enser Containment Float(s)and Chains Dispenser Containment Float(sj and Chain(s). *If the facility contains more tanks or dispensers,copy this farm. Indude information for every tank and dispenser at the facility. C. Certification - I cartify 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;(checkoff that apply): System set-up 7 Alarm history report Technician Name(print): David Walker Signature: ► �c d _ _ Certification No.: A32030 License.No.: 808313 Testing Company Name: Belshire Environmental Services, Inc. Phone No.: 9( 49 )460-5200 Testing Company Address: 25971 Towne Centre Dr.,Foothill Ranch,CA 92610 Date of Testing/Servicing: 6/28/2018 Monitoring System Certification Page 1 of 4 12107