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Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Piot Plan available at http://vmw.swreb.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 3,77tle 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 209167 Bldg.No.: Site Address: 1234 E.YOSEMITE AVE@ SPRECKLES City: MANTECA Zip: 95336 Facility Contact Person: MANAGER-KIM Contact Phone No.: 209-824-7433 Make/Model of Monitoring System: Veeder Root TLS-350 Date of Testing/Servicing: 2/12/2015 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: T:1-SUPREME Tank ID: T:2-REGULAR In-Tank Gauging Probe. Model: MAG 8473 17,;In-Tank Gauging Probe. Model: MAG 8463 R,Annular Space or Vault Sensor. Model: 794390909 r Annular Space or Vault Sensor. Model: 794390909 R Piping Sump/Trench Sensor(s). Model: 794380-208 P Piping Sump/Trench Sensor(s). Model: 794380-208 r Fill Sump Sensor(s). Model: r Fill Sump Sensor(s). Model: j Mechanical Line Leak Detector. Model: (Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Veeder Root PLLD Electronic Line Leak Detector. Model: Veeder Root PLLD Tank Overfill/High-Level Sensor.Model: FLAPPER ./j Tank Overfill/High-Level Sensor.Model: FLAPPER Other(specify equipment a and model in Section E on Pae 2). Other(sE)ecifv equipment a and model in Section E on Pae 2). Tank ID: Tank ID: I In-Tank Gauging Probe. Model: r 7 In Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: ri Annular Space or Vault Sensor. Model: n Piping Sump/Trench Sensor(s). Model: r] Piping Sump/Trench Sensor(s). Model: r Fill Sump Sensor(s). Model: r Fill Sump Sensor(s). Model: 17 Mechanical Line Leak Detector. Model: j Mechanical Line Leak Detector. Model: (j Electronic Line Leak Detector. Model: [j 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 Page rl Other(specify equipment a and model in Section E on Page 2). Dispenser 1/2 Dispenser 3/4 ID: ID: P Dispenser Containment Sensor(s).Model: 794380-208 r Dispenser Containment Sensor(s).Model: 794380-208 Shear Valve(s). r Shear Valve(s). I Dispenser Containment Float(s)and Chain(s). [ 1 Dispenser Containment Floats)and Chain(s). Dispenser 5/6 Dispenser 7/8 ID: ID: r Dispenser Containment Sensor(s).Model: 794380-208 Dispenser Containment Sensor(s).Model: 794380-208 r Shear Valve(s). r Shear Valve(s). Dispenser Containment Float(s)and Chain(s). r 1 Dispenser Containment Float(s)and Chain(s). Dispenser 9/10 Dispenser 11/12 ID: ID: r Dispenser Containment Sensor(s).Model: 794380-208 r!_e,;Dispenser Containment Sensor(s).Model: 794380-208 Shear Valve(s). ry—Oi Shear Valve(s). Dispenser Containment Float(s)and Chain(s). I ri Dispenser Containment Float(s)and Chain(s). *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 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):rk_6 System set- up �Alarm history report ,1rj1� Technician Name(print): Gilbert Garcia Signature: r_ c -f1_ Certification No.: 842816 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: 2/12/2015 Monitoring System Certification Page 1 of 3 12/07 *0-- PIVED AR 13 2015 EENVIRONMENTAL