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11 Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at hfp://www.swrcb.ca.gov.) MAR 2015 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 Facility Contact Person: MANAGER Contact Phone No. Make/Model of Monitoring System: Veeder Root TLS -350 B. Inventory of Equipment Tested/Certified !`I.e.•L hMu �nn.nn.:�fn Hn..un M :nA:n�M nnm.:An nn..: n.wunF :ncnnhnillmn.:nuA• City: STOCKTON 209-477-3699 Zip: 95212 Date of Testing/Servicing: 2/13/2015 Tank ID: T1 - SUPREME Tank ID: T2 - REGULAR 17 In -Tank Gauging Probe. Model: 847390-109 ry In -Tank Gauging Probe. Model: 847390-109 rV Annular Space or Vault Sensor. Model: 794390-409 ry Annular Space or Vault Sensor. Model: 794390-409 rvl Piping Sump / Trench Sensor(s). Model: 794380-208 rV Piping Sump / Trench Sensor(s). Model: 794380-208 Fill Sump Sensor(s). Model: r Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: r Mechanical Line Leak Detector. Model: rvl Electronic Line Leak Detector. Model: Veeder Root PLLD rO Electronic Line Leak Detector. Model: Veeder Root PLLD rV Tank Overfill / High -Level Sensor. Model: FLAPPER We Tank Overfill / High -Level Sensor. Model: FLAPPER 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: r In -Tank Gauging Probe. Model: r Annular Space or Vault Sensor. Model: r Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: r Piping Sump / Trench Sensor(s). Model: Fill Sump Sensor(s). Model: r Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: r Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: r Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: r Tank Overfill / High -Level Sensor. Model: Other(specify equipment a and model in Section E on Page 2). r Other (specify equipment a and model in Section E on Paige 2). Dispenser 1/2 Dispenser 3/4 ID: ID: rvo Dispenser Containment Sensor(s). Model: 794380-208 r Dispenser Containment Sensor(s). Model: 794380-208 rV Shear Valve(s). r Shear Valve(s). Dispenser Containment Float(s) and Chain(s). r Dispenser Containment Float(s) and Chain(s). Dispenser 5/6 Dispenser 7/8 ID: ID: jV Dispenser Containment Sensor(s). Model: 794380-208 Dispenser Containment Sensor(s). Model: 794380-208 vO Shear Valve(s). r4O Shear Valve(s). Dispenser Containment Float(s) and Chain(s). r Dispenser Containment Float(s) and Chain(s). Dispenser 9/10 Dispenser 11/12 ID: ID: r Dispenser Containment Sensor(s). Model: 794380-208 Dispenser Containment Sensor(s). Model: 794380-208 Shear Valve(s). r Shear Valve(s). Dispenser Containment Float(s) and Chain(s). I r Dispenser Containment Float(s) and Chain(s). 'Ir the facility contains more tanks or dispensers, copy this Corm. Include information for every tank and 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): W System set- up P Alarm history report Technician Name (print): David Mathie Signature: 14— Certification 4-Certification No.: A27397 License. No.: 743160 Class 'A' Testing Company Name: Tanknology Phone No.: (800) 800-4633 Testing Company Address: 11000 N, MoPac Expressway Suite 500 Date of Testing/Servicing: Monitoring System Certification Page 1 of 3 2/13/2015 12/07