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Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at hfp://vvww.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: CORNER STORE 3641 Site Address: 1210 E. HAMMER LANE@ WEST LANE Facility Contact Person: MGR - ALISA City: STOCKTON Contact Phone No.: 209.477-3111 Bldg. No.: Zip: 95210 Make/Model of Monitoring System: Gilbarco EMC Date of Testing/Servicing: 6/19/2013 B. Inventory of Equipment Tested/Certified Check the aourooriate boxes to indicate soecific eouioment inspected /serviced: Tank ID: T1 - UNLEADED Tank ID: T3 - PREMIUM In -Tank Gauging Probe. Model: MAG W, In -Tank Gauging Probe. Model: MAG Annular Space or Vault Sensor. Model: 420 ry_� Annular Space or Vault Sensor. Model: 420 Piping Sump / Trench Sensor(s). Model: 208 W Piping Sump / Trench Sensor(s). Model: 208 Fill Sump Sensor(s). Model: 208ry 1, Fill Sump Sensor(s). Model: 208 W. Mechanical Line Leak Detector. Model: Red Jacket FX1V [7 Mechanical Line Leak Detector. Model: Red Jacket FX1V r Electronic Line Leak Detector. Model: r Electronic Line Leak Detector. Model: r Tank Overfill /High Level Sensor. Model: r Tank Overfill / High -Level Sensor. Model: 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: T2- Enhanced Tank ID: rvo;; In -Tank Gauging Probe. Model: MAG r In -Tank Gauging Probe. Model: rV Annular Space or Vault Sensor. Model: 420 r Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: 208 [ 71 Piping Sump / Trench Sensor(s). Model: ', Fill Sump Sensor(s). Model: 208 r Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Red Jacket FX1V r Mechanical Line Leak Detector. Model: r Electronic Line Leak Detector. Model: r Electronic Line Leak Detector. Model: r Tank Overfill / High -Level Sensor. Model: r Tank Overfill / High -Level Sensor. Model: Other (soecify equipment a and model in Section E on Pae 2). Other(specify equipment a and model in Section E on Pae 2). Dispenser 1/2 Dispenser 7/8 ID: ID: r Dispenser Containment Sensor(s). Model: r Dispenser Containment Sensor(s). Model: Shear Valve(s). P7 Shear Valve(s). Wo Dispenser Containment Float(s) and Chain(s). rv. Dispenser Containment Float(s) and Chain(s). Dispenser 3/4 Dispenser ID: ID: r Dispenser Containment Sensor(s). Model: r Dispenser Containment Sensor(s). Model: r Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s) and Chain(s). r Dispenser Containment Float(s) and Chain(s). Dispenser 5/6 Dispenser ID: ID: r Dispenser Containment Sensor(s). Model: r Dispenser Containment Sensor(s). Model: r Shear Valve(s). r Shear Valve(s). r Dispenser Containment Float(s) and Chain(s). r 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): System set- up r. Alarm history report Technician Name (print): Sammy Till Certification No.: 842640 Testing Company Name: Tanknology Signature: License. No.: 743160 Class 'A' Phone No.: (800) 800-4633 Testing Company Address: 11000 N. MoPac Expressway Suite 500 Date of Testing/Servicing: 6/19/2013 Monitoring System Certification Page 1 of 3 12/07