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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: VALERO 3641 Bldg. No.: Site Address: 1210 E. HAMMER LANE@ WEST LANE Facility Contact Person: MGR - ALISA Make/Model of Monitoring System: Gilbarco EMC B. Inventory of Equipment Tested/Certified r'hme it thm mn nrimtim 1 nv M inAL•atm ifie• mnuinmmnt inenme+mA 1m 114 A. City: STOCKTON Zip: 95210 Contact Phone No.: 477-3111 Date of Testing/Servicing: 6/21/2012 Tank ID: T1 - UNLEADED Tank ID: T2 -Enhanced In -Tank Gauging Probe. Model: Mag r In -Tank Gauging Probe. Model: Mag Annular Space or Vault Sensor. Model: 460 P Annular Space or Vault Sensor. Model: 460 W Piping Sump / Trench Sensor(s). Model: 208 We Piping Sump / Trench Sensor(s). Model: 208 rV Fill Sump Sensor(s). Model: 208 Fill Sump Sensor(s). Model: 208 Mechanical Line Leak Detector. Model: Red Jacket FXIV P_ Mechanical Line Leak Detector. Model: Red Jacket FX1V r Electronic Line Leak Detector. Model: r Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: External Alarm r Tank Overfill / High -Level Sensor. Model: External Alarm Other(specify equipment a and model in Section E on Pae 2). Other(specify equipment a and model in Section E on Pae 2). Tank ID: T3 - PREMIUM Tank ID: ✓ In -Tank Gauging Probe. Model: Mag In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 460 r Annular Space or Vault Sensor. Model: W Piping Sump / Trench Sensor(s). Model: 208 r— Piping Sump / Trench Sensor(s), Model: W' Fill Sump Sensor(s). Model: 208 r Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Red Jacket FX1V Mechanical Line Leak Detector. Model: I— Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: External Alarm r Tank Overfill / High -Level Sensor. Model: r Other(specify equipment a and model in Section E on Page 2). Other(specify equipment a and model in Section E on Pae 2). Dispenser 1/2 Dispenser 3/4 ID: ID: Dispenser Containment Sensor(s). Model: r Dispenser Containment Sensor(s). Model: r' Shear Valve(s). rV 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: Dispenser Containment Sensor(s). Model: r- Dispenser Containment Sensor(s). Model: WO Shear Valve(s). We Shear Valve(s). r Dispenser Containment Float(s) and Chain(s). r Dispenser Containment Float(s) and Chain(s). Dispenser Dispenser ID: ID: Dispenser Containment Sensor(s). Model: I— Dispenser Containment Sensor(s). Model: Shear Valve(s). r Shear Valve(s). r Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). -it me tacnity contains more tanks or aispensers, copy mis rorm. inciuoe mrormanon ror every rank ano aispenser a< Me iacnicy. 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 Piot 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— System set- up I Alarm history report Technician Name (print): Kristopher Bell Certification No.: 833709 Testing Company Name: Tanknology Signature: Av�_ License. No.: 743160 Class 'A' Phone No.: (800) 800-4633 Testing Company Address: 11000 N. MoPac Expressway Suite 500 Date of Testing/Servicing: 6/21/2012 Monitoring System Certification Page i of 3 12/07