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10 0 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 Zip: 95212 Facility Contact Person: MANAGER Contact Phone No.: 477-3699 Make/Model of Monitoring System: Veeder Root TLS -350 Date of Testing/Servicing: 2/22/2013 B. Inventory of Equipment Tested/Certified rhark tha annrnnriata hnvac to indirata cnarifir anninmant incnartad lc mirade Tank ID: TI - SUPREME Tank ID: T2 - REGULAR In -Tank Gauging Probe. Model: mag r✓', In -Tank Gauging Probe. Model: mag Annular Space or Vault Sensor. Model: 409 r11 Annular Space or Vault Sensor. Model: 409 Piping Sump / Trench Sensor(s). Model: 208 Jr✓' Piping Sump / Trench Sensor(s). Model: 208 Fill Sump Sensor(s). Model: r Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Ir 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: flapper Tank Overfill / High -Level Sensor. Model: flapper Other(specify equipment a and model in Section E on Pa e 2). r Other (specify equipment a and model in Section E on Pa e 2). Tank ID: Tank ID: In -Tank Gauging Probe. Model: r In -Tank Gauging Probe. Model: 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: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: r Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: I Tank Overfill / High -Level Sensor. Model: 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 . Dispenser 1/2 Dispenser 3/4 ID: ID: 17 Dispenser Containment Sensor(s). Model: 208 Dispenser Containment Sensor(s). Model: 208 W Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser 5/6 Dispenser 7/8 ID: ID: r', Dispenser Containment Sensor(s). Model: 208 rV Dispenser Containment Sensor(s). Model: 208 rl_,� Shear Valve(s). W Shear Valve(s). r Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser 9/10 Dispenser 11/12 ID: ID: rV Dispenser Containment Sensor(s). Model: 208 Dispenser Containment Sensor(s). Model: 208 W Shear Valve(s). r' Shear Valve(s). Dispenser Containment Float(s) and Chain(s). r` Dispenser Containment Float(s) and Chain(s). -it the racnity contains more tanks or aispensers, copy tins rorm. incivae inrormation tor every tanK ana aispenser at the racinty. 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): r-11. System set- up P Alarm history report Technician Name (print): Steven Willems Certification No.: B36743 Testing Company Name: Tanknology Testing Company Address: 11000 N. MoPac Expressway Suite 500 Monitoring System Certification Signature: ��xxuv License. No.: 743160 Class'A' Phone No.: (800) 800-4633 Page 1 of 3 Date of Testing/Servicing: 2/22/2013 12/07