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Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.waterboards.ca.gov.) 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. 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:_10/25/17 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID:_1 Diesel Tank ID: x In-Tank Gauging 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/Trench Sensor(s). Model:_VR 208 ❑ Piping Sump/Trench Sensor(s). Model: x Fill Sump Sensor(s). Model:_VR 208 El Fill Sump SensModel: x Mechanical Line Leak Detector. Model:_VMI LD 2000 ❑ Mechanical Linee Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: El Line Leak Detector. Model: El Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment t e 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/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment t e and model in Section E on Page 2). ❑ Other(specify equipment t e 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 ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ 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 ❑ ShearValve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dispenser 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 Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chains ❑ Dispenser 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 inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification are 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): ❑System set-up ❑Alarm history report Technician Name(print):John Puumala Signature: Certification No.: A29358 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:_10-25-17 Monitoring System Certification Page 1 of 4 12/07 1 2/21/07