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RECEIVO AUG 1 1 2017 "xi, . �_ ,j Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Pla v�ileble-W hito/,1WW*4rate&b_6a v.) MONITORING SYSTEM CERTIFICATIONS 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 Manteca CO MNTCCAXG82A Facility Name: Bldg.No.: Site Address. 430 W.Center Street,Manteca,CA 95336 Facility Contact Person: Richard Silvera Contact Phone No.: (209)892-0256 MakeWodel of Monitoring System:Veederoot TLS 350 Date of Test!ngfServicing:8/3/2017 B. Inventory of Equipment Tested/Certified Check the a ro riate boxes to indicatespecific 2quipment ins ected1serviced: Tank ID:TGO13935/diesel 16,000 Tank ID: 17-1 in-Tank Gauging Probe. Model 847390.-107__._._.__.._......__....._ ❑ In-Tank Gauging Probe. Model:__..__..........-_--___-_.... j]Annular Space or Vault Sensor, Model: 794380-320 ___._.._..._.__._. Q Annular Space or Vault Sensor. Model: Q Piping Sump/Trench Sensor(s). Model:,794380-350 ❑ Piping Sump/Trench Sensor(s). Model: (�Fill Sump Sensor(s). Model:,794380-350 ❑ Fill Sump Sensor(s). Model: ❑Mechanical Line Leak Detector. Model:_._ _ Mechanical Line Leak Detector. Model:_ Electronic Line Leak Detector. Model:_,. Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: mechanical/790091-0( Q Tank Overfill/High-Level Sensor. Model: Q Other(specify e ui ment tyee and model in Section E on Pae 2). ❑Other(specify equipment t e and model in Section E on Page 2). Tank ID. Tank ID: ❑In-Tank Gauging Probe. Model: _ ❑In-Tank Gauging Probe. Model: Q Annular Space or Vault Sensor. Model: ❑Annular Space or Vault Sensor. Model: ❑Piping Sump/Trench Sensor(s). Model ❑Piping Sump/Trench Sensor(s). Model: ❑Fill Sump Sensor(s). Model: Q Fill Sump Sensor(s). Model:_.............................................................................. ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model:m._. ,,,,,............... ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: Q Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill/High-Level Sensor. Model: Other(specify equipment t e and model in Section E on Pa e 2). Other s ecif e ui ment type and model in Section E on Pa e 2). DispenserlD: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). Shear Valve(s). Dispenser Containment Floats and Chains. Dispenser Containment Float6s and Chain(s). Dispenser ID: - Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chains. Dis enser Containment Floats and Chains. Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s), Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chains Dispenser Containment Fioat(5 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 Flan 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 EAlarm history report Technician Name(print): David Smith David Smith a (p ) Signature:____ Certification No.: 8260473 License.No.: 703190 Testing Company Name: SunWest Engineering Const„Inc. Phone No.:888-588-8737 Testing Company Address: 4780 Cheyenne Way,Chino,CA 91710 Date of Testing,Servicing: 8/3/2017 Monitoring System Certification Page 1 of 4 12107 QA/QC APPROVED 8/4/20179:28 AMBrandon Bo 1 2/21!()7