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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 T CERTIFICATION For Use By All Jurisdictions Within the State of Caldbmia Authority Cited. Chapter 6.7, Health and Safety Code; Chapter 96, Division 3, Title 23, Califomia 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: _Dave Nelson Contact Phone No.: 916-371-2570 Make/Model of Monitoring System: —TLS -350 Date of Testing/Servicing: _10/30/13 B. Inventory of Equipment Tested/Certified Check the aDiorooriate boxes to Indicate specific equipment ins cted/serviced: Tank ID: Diesel Tank to: x _1 In -Tank Gauging Probe. Model: Mag 1 ❑ In -Tank Gauging Probe. Model: x Annular Space or Vault Sensor. Model: _VR 303 u Annular Space or Vault Sensor. Model: x Piping Sump / Trench Sensor(s). Model: VR 208 El Piping Sump 1 Trench Sensor(s). Fill Sump Sensor(s). Model: Model: x Fill Sump Sensor(s). Model: VR 208 ❑ F! Mechanical Line Leak Detector. Le. Model: x Mechanical Line Leak Detector. Model: _VMI LD 2000 ❑ Electronic Line Leak Model: ❑ Electronic Line Leak Detector. Model: ❑ SenDetector. Tank Overfill / High-level Sensor. High-Level Model: 0 Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other ui ment and model seci in Section E on Page 2 . Tank 10: Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: D Annular Space or Vault Sensor. Model: 0 Piping Sump / Trench Sensor(s). Model: 0 Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: D Fill Sump Sensor(s). Model: 0 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 a ui ment a and model in Section E on Page 2). ❑ s cin E on Pa e 2 . Otherui ment a and model in Sectio 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). Li Shear Valve(s). 0 Disp2nser Containment Floats and Chain(s). :i Dis nser 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). 0 Shear Valve(s). ❑ Dispenser ContalnMg2 Float s and Chains . ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: _Satellite _2-3 Dispenser ID: —5— * Dispenser Containment Sensor(s). Model: VR 208 x Dispenser Containment Sensor(s). Model: _VR 208 ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dise2neer Containment Floats and Chains ❑ Dis nser Containment Floats and Chaln s . `If the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the faciky. 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 Piot 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): ASystem set-up ^Ianm history report Technician Name (print): John Puumala Signature: Certification No.: A29358 Li ns o.: 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: _10-30/13 Monitoring System Certification Page 1 of 4 12/07 2/21/07