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RECEIVED Appendix VI ggg2014 (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.sw ) MONITORING SYSTEM CERTIFICATION ENVIRONMENTAL For Use By All Jurisdictions Within the State of California HEALTH DEPARTMENT 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.General Information Facility Name: CHEVRON#201383(N-2515-1-1) Bldg.No.: Site Address: 1960 W. 11TH STREET@ CORRAL HOLLOW City: TRACY Zip: 95376 Facility Contact Person: MGR-HELEN Contact Phone No.: 209-836-3181 Make/Model of Monitoring System: Veeder Root TLS350 Date of Testing/Servicing: 2/13/2014 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment ins cted serviced: Tank ID: Tl-SUPREME Tank ID: T2-PLUS rvo In-Tank Gauging Probe. Model: mag r', In-Tank Gauging Probe. Model: mag Annular Space or Vault Sensor. Model: yr-409 Annular Space or Vault Sensor. Model: yr-409 Piping Sump/Trench Sensor(s). Model: yr-208 r%O Piping Sump/Trench Sensor(s). Model: yr-208 Fill Sump Sensor(s). Model: yr-208 rV Fill Sump Sensor(s). Model: yr-208 Mechanical Line Leak Detector. Model: r Mechanical Line Leak Detector. Model: ✓' Electronic Line Leak Detector. Model: Veeder Root PLLD W Electronic Line Leak Detector. Model: Veeder Root PLLD rV_'Tank Overfill/High-Level Sensor.Model: flapper ry Tank Overfill/High-Level Sensor.Model: flapper Other(sDecify equipment a and model in Section E on Pa e 2 . '; Other(specify equipment a and model in Section E on Pae 2). Tank ID: T3-REGULAR Tank ID: W In-Tank Gauging Probe. Model: mag In-Tank Gauging Probe. Model: w;, Annular Space or Vault Sensor. Model: vr-409 Annular Space or Vault Sensor. Model: rV Piping Sump/Trench Sensor(s). Model: yr-208 r Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: yr-208 Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: ry Electronic Line Leak Detector. Model: Veeder Root PLLD Electronic Line Leak Detector. Model: Wo Tank Overfill/High-Level Sensor.Model: flapper r Tank Overfill/High-Level Sensor.Model: Other(specify equipment a and model in Section E on Pae 2). Other(specify equipment a and model in Section E on Pae 2).__ Dispenser 1/2 Dispenser 3/4 ID: ID: r1_1I Dispenser Containment Sensor(s).Model: yr-208 r Dispenser Containment Sensor(s).Model: yr-208 Shear Valve(s). r,4O Shear Valve(s). Dispenser Containment Float(s)and Chain(s). r Dispenser Containment Float(s)and Chain(s). Dispenser 5/6 Dispenser 7/8 ID: ID: rvP Dispenser Containment Sensor(s).Model: yr-208 rV Dispenser Containment Sensor(s).Model: yr-208 r Shear Valve(s). WO Shear Valve(s). r Dispenser Containment Float(s)and Chain(s). r— Dispenser Containment Float(s)and Chain(s). Dispenser 9/10 Dispenser 11/12 ID: ID: Dispenser Containment Sensor(s).Model: yr-208 Dispenser Containment Sensor(s).Model: yr-208 rV Shear Valve(s). rV Shear Valve(s). Dispenser Containment Float(s)and Chain(s). r 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-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):W.System set- up W Alarm history report Technician Name(print): Brent Bowen Signature: M Certification No.: 842815 License.No.: 743160Class'A' Testing Company Name: Tanknology Phone No.: (800)800-4633 Testing Company Address: 11000 N.MoPac Expressway Suite 500 Date of Testing/Servicing: 2/13/2014 Monitoring System Certification Page 1 of 3 12/07