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C Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.swrcb.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: CHEVRON 208118 N-4087-1-3 Bldg. No.: Site Address: 3355 E. HAMMER LANE@ HOLMAN RD City: STOCKTON Facility Contact Person: MANAGER Contact Phone No.: 209-477-3699 Make/Model of Monitoring System: Veeder Root TLS -350 B. Inventory of Equipment Tested/Certified rk.,L eai.n i--- t- .Hued.., incn.-+. ! I—i-1- Zip: 95212 Date of Testing/Servicing: 2/6/2017 Tank ID: Tl - SUPREME Tank ID: T2 - REGULAR In -Tank Gauging Probe. Model: 846390-109 In -Tank Gauging Probe. Model: 846390-109 Annular Space or Vault Sensor. Model: 794390-409 Annular Space or Vault Sensor. Model: 794390-409 (d Piping Sump / Trench Sensor(s). Model: 794380-208 PF Piping Sump / Trench Sensor(s). Model: 794380-208 Fill Sump Sensor(s). Model: J. Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: (- Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Veeder Root PLLD - r Electronic Line Leak Detector. Model: Veeder Root PLLD - Tank Overfill / High -Level Sensor. Model: FLAPPERS ry—F; Tank Overfill / High -Level Sensor. Model: FLAPPERS Other(specify equipment a and model in Section E on Pae 2). r Other (specify equipment a and model in Section E on Pae 2). Tank ID: Tank ID: 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: r 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 a and model in Section E on Pae 2). Other(specify equipment a and model in Section E on Pae 2). Dispenser 1/2 Dispenser 3/4 ID: ID: r' Dispenser Containment Sensor(s). Model: 794380-208 r Dispenser Containment Sensor(s). Model: 794380-208 Shear Valve(s). ry_� Shear Valve(s). Dispenser Containment Float(s) and Chain(s). 1_� Dispenser Containment Float(s) and Chain(s). Dispenser 5/6 Dispenser 7/8 ID: ID: r7 Dispenser Containment Sensor(s). Model: 794380-208 P7 Dispenser Containment Sensor(s). Model: 794380-208 �" Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser 9/10 Dispenser 11/12 ID: ID: Dispenser Containment Sensor(s). Model: 794380-208 Dispenser Containment Sensor(s). Model: 794380-208 Shear Valve(s). 17 Shear Valve(s). Dispenser Containment Float(s) and Chain(s). r Dispenser Containment Float(s) and Chain(s). -it the racaity contains more tames or dispensers, copy tnis torm. incivae mtormation tor every tanK ana aispenser at the racn¢y. C. Certification - I certify that the equipment identified in this document was inspected/serviced 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): W System set- up Alarm history report Technician Name (print): Jesus Saldivar Certification No.: 845334 Testing Company Name: Tanknology Signature: License. No.: 743160 Class'A' Testing Company Address: 11000 N. MoPac Expressway Suite 500 Monitoring System Certification Page i Phone No.: (800) 800-4633 Date of Testing/Servicing: 2/6/2017 12/07