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Appendix VI FEB 2 6 2016 (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.swrcb.ca.gov.) MONITORING SYSTEM CERTIFICATION ENVIRONMENTAL For Use By All Jurisdictions Within the State of California Y A IT nCPA PTkAMNlT 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 Zip: 95212 Facility Contact Person: MANAGER Contact Phone No Make/Model of Monitoring System: Veeder Root TLS -350 B. Inventory of Equipment Tested/Certified Check the nnnrnnriata h—c to int irata cnari£r amolnmant inenartarirea—irad. 209-477-3699 Date of Testing/Servicing: 2/9/2016 Tank ID: TI - SUPREME Tank ID: T2 - REGULAR In -Tank Gauging Probe. Model mag r�—oj In -Tank Gauging Probe. Model: mag ±+? Annular Space or Vault Sensor. Model: 409 r Annular Space or Vault Sensor. Model: 409 P Piping Sump / Trench Sensor(s). Model: 208 P' Piping Sump / Trench Sensor(s). Model: 208 Fill Sump Sensor(s). Model: r' Fill Sump Sensor(s). Model: r Mechanical Line Leak Detector. Model: r7 Mechanical Line Leak Detector. Model: R Electronic Line Leak Detector. Model: Veeder Root PLLD r Electronic Line Leak Detector. Model: Veeder Root PLLD r Tank Overfill / High -Level Sensor. Model: flapper r Tank Overfill / High -Level Sensor. Model: flapper Other(specify equipment t e and model in Section E on Page 2). Other(specify equipment t e and model in Section E on Pa e 2). Tank ID: Tank ID: rIn-Tank Gauging Probe. Model: r In -Tank Gauging Probe. Model: ri Annular Space or Vault Sensor. Model: r-7 Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: r7j Piping Sump / Trench Sensor(s). Model: r Fill Sump Sensor(s). Model: r Fill Sump Sensor(s). Model: rMechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: r• Electronic Line Leak Detector. Model: rlElectronic Line Leak Detector. Model: j Tank Overfill / High -Level Sensor. Model: r7 Tank Overfill / High -Level Sensor. Model: i Other(specify equipment a and model in Section E on r Other(specify equipment a and model in Section E on Page 2). Dispenser 1/2 Dispenser 3/4 ID: ID: r Dispenser Containment Sensor(s). Model: 208 r Dispenser Containment Sensor(s). Model: 208 r Shear Valve(s). r70%' Shear Valve(s). r Dispenser Containment Float(s) and Chain(s). j Dispenser Containment Float(s) and Chain(s). Dispenser 5/6 Dispenser 7/8 ID: ID: P Dispenser Containment Sensor(s). Model: 208 r Dispenser Containment Sensor(s). Model: 208 r Shear Valve(s). (±/j Shear Valve(s). Dispenser Containment Float(s) and Chain(s). I Dispenser Containment Float(s) and Chain(s). r Dispenser 9/10 Dispenser 11/12 ID: ID: Dispenser Containment Sensor(s), Model: 208 C' Dispenser Containment Sensor(s). Model: 208 Shear Valve(s). I!—ej Shear Valve(s). r Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). "7r me Tacwty contains more tanks or aispensers, copy mis rorm. incwae intormation for every tank ana dispenser at the tacility. 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): Pl System set- up P, Alarm history report Technician Name (print): Jarrod Cooke Certification No.: B35255 Testing Company Name: Tanknology Signature: License, No.: 743160 Class 'A' Phone No.: (800) 800-4633 Testing Company Address: 11000 N. MoPac Expressway Suite 500 Monitoring System Certification Page i of 3 Date of Testing/Servicing: 2/9/2016 AA/U/