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RECEIVED • NOV 0 7 2016 Appendix VI ENVIRONMENTAL HEALTH (Copies of Monitoring System Certification form and UST Monitoring Piot Plan available at hftp://www.watergg§M SES MONITORING SYSTEM CERTIFICATION For Use By Aff Junsdkdons Within the State of Ca/ifomia 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: _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/Model of Monitoring System:TLS-350 Date of Testing/Servicing:_10127/16 B. Inventory of Equipment Tested/Certified Check the approLnate boxes to indicates ific!guipment insl ectediserviced: Tank ID: 1 Diesel Tank ID: x In-Tank G_auging Probe. Model:_Mag 1 ❑ In-Tank Gauging Probe. Model: x Annular Space or Vault Sensor. Model: VR 303 ❑ Annular Space or Vault Sensor. Model: x Piping Sump I Trench Sensor(s). Model: VR 208 ❑ Piping Sump/Trench Sensor(s). Model: x Fill Sump Sensor(s). Model:_VR 20811 Fill Sump Sensor(s). Model: x Mechanical Line Leak Detector. Model: VMI LD 2000 ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electrons Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank (specify it/equipment Sensor. Model: ❑ Others ui ment and model in Section E on Page 2. ❑ Other(specify equipment type 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: ❑ Fill 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 l High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specil equipment and model in Section E on Pa 2. ❑ Other(suipTent and model in Section E on Pa Dispenser ID:_1-2 Dispenser ID:_3.4 x Dispenser Containment Sensor(s). Model:_VR 208 x Dispenser Containment Sensor(s). Model: VR 208 ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment F12atLsj and Chain(!;). ❑ Dispenser Containment Floats and Chain(s). Dispenser ID:_Satellite 1 Dispenser ID:_Satellite 4-5 x Dispenser Containment Sensor(s). Model: VR 208 x Dispenser Containment Sensor(s). Model: VR 208 ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment FloatW and Chain(s). ❑ Dis enser Containment Floats and Chain(s). Dispenser ID:_Satellite_2-3 Dispenser ID:_5 x Dispenser Containment Sensor(s). Model: VR 208 x Dispenser Containment Sensor(s). Model: VR 208 ❑ Shear Vatve(s). ❑ Shear Valve(s). ❑ Disp2nser Containment Floats and Chains ❑ Disp2nser Containment Floats 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 inspectediserviced in accordance whit the manufacturers' guidelines. Attached to this Certification are information(e.g.manufacturers'checklists)necessary to verify that this information is correct and a Plot Pian showing the layout of monitoring equipment For any equipment capable of generating such reports,1 have also attached a copy of the report,(check all that apply): ❑System set-up ❑Alarm history report Technician Name(print):Gabe Garcia Signature: ./`�G � Certification No.: 842919 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 Testing/Servicing:_10-27-16 Monitoring System Certification Page 1 of 4 12/07 1 2/21/07 Po505u�