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f 0 REcEIVED Appendix V1 NOV 10 201? (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at httD://wwvJ.4fii%tLoards.ca.qov.) .Wj[jVW1VTAL MONITORING SYSTEM CERTIFICATION AftjTISEI? HE4L-rpj For Use By All Jurisdictions Within the State of Calffibmia WCES 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 sp!cific equipment ins l ectediserviced: Tank ID: 1 Diesel Tank ID: x In-Tank Gauging Probe. Model: Mag I In-Tank Gauging Probe. Model: x Annular Space or Vault Sensor. Model:- ii VR 303 11 Annular Space or Vault Sensor. Model: x Piping Sump I Trench Sensor(s). Model:-VR 208 0 Piping Sump/Trench Sensor(s). Model: x Fill Sump Sensor(s). Model:-_VR 208 o Fill Sump Sensor(s). Model: x Mechanical Line Leak Detector. Model:-VMI LD 2000 11 Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model:- o Electronic Line Leak Detector. Model: o Tank Overfill/High-Level Sensor. Model: 11 Tank Overfill/High-Level Sensor. Model: 11 Other LsjLeci!y equipment!ype and model in Section E on Page 2). u Other(specify equipment type and model in Section E on Page 2). TankID: TankID: 0 In-Tank Gauging Probe. Model: F1 In-Tank Gauging Probe. Model: 0 Annular Space or Vault Sensor. Model: Ei Annular Space or Vault Sensor. Model: El Piping Sump/Trench Sensor(s). Model: o Piping Sump/Trench Sensor(s). Model: El Fill Sump Sensor(s). Model: [i Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: 11 Mechanical Line Leak Detector. Model: o Electronic Line Leak Detector. Model: o Electronic Line Leak Detector. Model: U Tank Overfill/High-Level Sensor. Model: 0 Tank Overfill/High-Level Sensor. Model: 11 Other�snci2 2quipment e and model in Section E on Page 2). El Others ci!y 9quipment!yp2 and model in Section E on Dispenser ID: 1-2 Dispenser ID: 3-4 x Dispenser Containment Sensor(s). Model:—VR 208 x Dispenser Containment Sensor(s). Model:-VR 208 El Shear Valve(s). ii Shear Valve(s). 0 Dispenser Containment Float(s)and Chain(s). 11 Dispenser Containment Float(s)and Chains. 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 0 Shear Valve(s). ii Shear Valve(s). 0 Dispenser Containment Float(s)and Chain(s). 0 Dis[!2nser Containment Float(s)and Chain(s). IN Dispenser ID:—Satellite-2-3 Dispenser ID:—5 x Dispenser Containment Sensor(s). Model:-VR 208 x Dispenser Containment Sensoqs). Model:—VR 208 0 Shear Valve(s). 0 Shear Valve(s). 11 Disp2nser Containment Floats )and Chains 11 Dispenser Containment Float(s)and Chain(sJ. *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 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 monitorinpequipment. For any equipment capable of generating such reports,I have also attached a copy of the report;(check all that apply): /XSystem set-up larm history report Technician Name(print):John Puumala Signa Certification No.: A29358 (LicenZNo.-. 811471 Testing Company Name:—JP Petroleum Service Phone No4_916)_�372-5693 Testing Company Address:3065 Asante Lane, W. Sacto Ca 95691 Date of Testing/Servicing:—10-25-17 Monitoring System Certification Page I of 4 12107 1 2/21/07