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RECEIVED Appendix V1 j&V (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at vww.wat MONITORING SYSTEM CERTIFICATION ENWRONMENTALHEALTIJ For Use By All Jurisdictions Within the State of CaliforniaPERMIT/f R jj 4 Authority Cited. Chapter &7, Health and Safety Code; Chapter 16, Division 3, Title 23, Califomia o eC4F 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 Bldg. No.: Facility Name: —Ramos Oil Company — French Cam Site Address: 10842 South Harlan Road_ City: French Camp— ZIP: -95231 Facility Contact Person: –Sam Delgado_ Contact Phone No.: (__,916_1_371-2570_ Make/Model of Monitoring System: TLS -350 Date Date of Testing/Servicing: _1 0—/-31–/-201 2�_ B. Inventory of Equipment Tested/Certified % *If the facility contains more tanks or dispen5cm, uuijy t, C. Certification - I certify that the equipment Identified in this document was Inspectediserviced in accordance with the manufacturers' guidelines. Attached to this Certification is 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): e -System set-up ;kAlaffn history report Technician Name (print): John Puumal8 Signatul Certification No.: -A29358 .. 'I Cl– _r,�-2 �06- Licen[Z5.: -811471 Testing Company Name: —JP Petroleum Service_ Phone No.:( -91 S_J__�372-5693� Testing Company Address: 3065 Asante Lane, W. Sacto Ca 95691_ Date of Testing/Servicing: _10! 31 / 2012 Monitoring System Certification Page I of 4 12107 2/21/07 Check the ageroeriate boxes to indicate SM111c 29U men Ins Tank ID: Tank ID: —1 Diesel Ei In -Tank Gauging Probe. Model: x in -Tank Gauging Probe. Model: i❑i -0 Annular Space or Vault Sensor. Model: x Annular Space or Vault Sensor. Model: VR303 Piping Sump I Trench Sensor(s) Model: x Piping Sump / Trench Sensor($) Model: VR208 o Fill Sump Sensor(s). Model: x Fill Sump Sensor(s). Model: VR 208 o Mechanical Line Leak Detector. Model: o Mechanical Line Leak Detector- Model: o Electronic Line Leak Detector. Model: o Electronic Line Leak Detector. Model: o Tank Overfill / High -Level Sensor. Model: Ci Tank Overfill I High -Level Sensor. Model: o Other (specify equipment type and model in Section E on Page 2). c Other (seci!y Nuipment!ype and model in Section E on Page Tank ID: T Tank ID: u In -Tank Gauging Probe. Model: o In -Tank Gauging Probe. Model: o Annular Space or Vault Sensor. Model: o Annular Space or Vault Sensor. Model. Model: c Piping Sump / Trench Sensor(s). Model: ii Piping Sump / Trench Sensor(s). Model: F, Fill Sump Sensor(s). Mechanical Line Leak Detector. Model: Model: u n Fill Sump Sensor(s)- Mechanical Line Leak Detector. Model: ri [j Electronic Line Leak Detector. Model: ri Electronic Line Leak Detector. Model: Model: o Tank Overfill I High -Level Sensor. Model: Section E Pa2L i i n Tank Overfill / High -Level Sensor. Other Lspea!9u!pment!Xpe and model in Section Eon Pa 0 Other (seee equ!pTent!X22 and model in on ie Dispenser ID: Satelite I x Dispenser Containment Sensor(s). Model: VR 208, Dispenser ID: _Master 3-4 x Dispenser Containment Sensor(s). Model: —VR 208 o Shear Valve(s). ❑Shear 0 Valve(s). Dispenser Containment Floats ) and Chaln(s)- 11 Dismser Containment Float(s) and Chain(s). - Dispenser ID: _Master 1-7 X Dispenser Containment Sensor(s). model; VR 205 Dispenser ID: —sateffte 45 x Dispenser Containment Sensor(s). Model: VR 208 — 0 ShearVatve(s). 0 11 Shear Valve(s). Disp r Containment Float(s) and Chainus 0 Dispenser Containment Floats and Chain(s). Dispenser 10: __�Saielite 2--2 x Dispenser Containment Sensor(s). Model: 208 LDIspenser ID: _Master 5 x Dispenser Containment Sensor(s). Model: —VR 208_ Fj Shear Valve(s). —VR Ei r i I Shear Valve(s). is and Dispenser Containment Floats Chain(s). l: i Disp2nser Containment Floats and Chains *If the facility contains more tanks or dispen5cm, uuijy t, C. Certification - I certify that the equipment Identified in this document was Inspectediserviced in accordance with the manufacturers' guidelines. Attached to this Certification is 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): e -System set-up ;kAlaffn history report Technician Name (print): John Puumal8 Signatul Certification No.: -A29358 .. 'I Cl– _r,�-2 �06- Licen[Z5.: -811471 Testing Company Name: —JP Petroleum Service_ Phone No.:( -91 S_J__�372-5693� Testing Company Address: 3065 Asante Lane, W. Sacto Ca 95691_ Date of Testing/Servicing: _10! 31 / 2012 Monitoring System Certification Page I of 4 12107 2/21/07