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Sl Appendix V1 (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.waterboards.ca.gov.) MONITORING SYSTEM CERTIFICATION For Use By AM JurlsdkUons Within the State of California Authority Cited. Chapter 6.7, Health and Safety Code;Chapter 16, Division 3, Title 23, Calffomia 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 LIST systems within 30 days of test date. A. General Information Facility Name: —Ramos Oil Company Bldg.No.: Site Address:—10842 S. Harlan Road city:-French Camp— zip: Facility Contact Person:—Steve Richardson Contact Phone No.:916-371-2570 make/modei of monitoring system:—TLS-350 Date of Testing/servicing:_14/25/18 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicate sa—cifir equipment Insl ectediserviced: Tank 10: 1 Diesel Tank ID: x lnTank�auging Probe. Model: Mag 1 0 In-Tank Gauging Probe. Model: x Annular Space or Vault Sensor. Model:-VR 303 0 Annular Space or Vault Sensor. Model: x Piping Sump I Trench Sensor(s). Model:_VR 2080 Piping Sump/Trench Sensor(s). Model: x Fill Sump Sensor(s). Model: VR 208— u Fill Sump Sensor(s). Model: x Mechanical Line Leak Detector. Model:-VMI LD 2000 0 Mechanical Line Leak Detector. Model: Electronic line Leak Detector. Model:- 0 Electronic Line Leak Detector. Model: 11 Tank Overfill/High-Level Sensor. Model: ol Tank Overfill/High-Level or. Model: 0 Other(specify equipment type and model In Section E on Page 2). ro Other(specify equjem2l!j��Iin Se�cfion E on�Page 2�)_ TankID: TankID: n In-Tank Gauging Probe. Model: U In-Tank Gauging Probe. Model: o Annular Spam or Vault Sensor. Model: 0 Annular Space or Vault Sensor. Model: Ei Piping Sump/Trench Sensor(s). Model: 11 Piping Sump I Trench Sensor(s). Model: ii Fill Sump Sensor(s). Model: Li Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: 11 Mechanical Line Leak Detector. Model: El Electronic Une Leak Detector. Model: 0 Electronic Line Leak Detector. Model: 0 Tank Overfill/High-Level Sensor. Model: 0 Tank Overfill I High-Level Sensor. Model: ii Others 29u' and model in Section E on Pa 2). 0 2j2LjLsg2&2guknent and model in Section E on Page 2). Dispenser ID:—1-2 Dispenser ID:—3-4 x Dispenser Containment Sensor(s). Model:_VR 208_ x Dispenser Containment Sensor(s). Model:_VR 208 0 Shear Valve(s). 0 Shear VaWs). o Disp2nser Containment Dpajt 0 and ChainW. -, Disp2nser Contairtment Float and Chain(s). Dispenser 10:—Satellite I Dispenser 10:—Satellite 4-5 x Dispenser Containment Sensor(s). Model:_VR 208 x Dispenser Containment Sensor(s). Model:_VR 208 0 Shear Valve(s). 0 Shear Valve(s). 0 Dispenser Containment 52! sand Chalns). 0 Disonser Containment 5MtLs)and Chaln(s). .1 ( Dispenser 10:—Satelfite 2-3 Dispenser 10: 5 x Dispenser Containment Senson(s). Model:_VR 208 x Dispenser Containment Sensor(s). Model:_VR 208 0 Shear Valve(s). 0 Shear Va"s). 0 Dls�nser ContainrneqEgat Us and Chains u Disg2nser Containment Lsj and Chins j. *If the facility contains more tanks or dispensers,copy this form. Include Information for every tank and dispenser at the facility. C. Certification - I certity that the equipment Identified In this document was inspectediserviced In accordance with the manufacturers! guidelines. Attached to this Certification are info(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 aff OW apply): 0 System set-up 0 Alarm hist, rert, Technician Nam(print):Gabe Garcia Signature: Certification No.: B42919 License.No.: 811471 Testing company Name._JP Petroleum Service Phone No.:( 916 ) 372-5693 Testing Company Address:3065 Asante Lane, W. Sacto Ca 95691 Date of Testingiservicing:—10-25-18 Monitoring System Cedificadort Page I of 4 12f07 1 2/21/07