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RECEIVED NOV 0 9 2015 Appendix V1 E'NVIRONMENT�, (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at httl,:/fv �r.v TR MONITORING IFI I 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:_10/29/15 B. Inventory of Equipment Tested/Certified Check the appro riate boxes to indicates ecific 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 303F, 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 Fill Sump Sensor(s). Model: x Mechanical Line Leak Detector. Model:_VMI LD 2000 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: L Other s eci 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: _j 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: r; Electronic Line Leak Detector. Model: - Electronic Line Leak Detector. Model Tank Overfill/High-Level Sensor. Model: Tank Overfill/High-Level Sensor. Model: F] Others cify a ui men4 a and model in Section E on Pa e 2. Other(specify equipment a and model in Section Eon PaLe 2). Dispenser ID:_1-2 1 Dispenser ID:_3-4 x Dispenser Containment Sensor(s). Model:_VR 208 x Dispenser Containment Sensor(s). Model:_VR 208 I-,, Shear Valve(s). Shear Valve(s). C 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 i-, Shear Valve(s). Shear Valve(s). -1 Dispenser Containment Floats and Chain(s). Dispenser Containment Float(s)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 n Shear Valve(s). 1 i Shear Valve(s). n Dis enser Containment Float(s)and Chains Dispenser Containment Floats and Chains. "If the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility. C. Certification - 1 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,1 have also attached a copy of the report;(check all that apply): 4 System set-up V Alarm history report Technician Name(print):John PUumala Signatur Certification No.: A29358 e.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:_10-29-15 Monitoring System Certification Page 1 of 4 12!07 1 2/21/07