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Appendix V1 AUG 15 2016 (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at httj?://wwvv.waterb::: 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 LIST systems within 30 days of test date. A. General Information Facility Name: Manteca CO Bida.No.:CA4784419 Site Address: 430 W.Center Street,Manteca,CA 95336 Facility Contact Person: Vincent Scheaffer Contact Phone No.: (209)401-4547 Make!Model of Monitoring System:Veederoot TLS 350 Date of Testing/Servicing:2016-08-03 B. Inventory of Equipment Tested/Certified Check the aleerclaiate boxes to indicate sE!ecific 2quipment ins cted/serviced: TankID:TGO13935 i`diesel 16,000 gallon Tank ID: 0 In-Tank Gauging Probe. Model: 847390-107 ❑ In-Tank Gauging Probe. Model: El Annular Space or Vault Sensor. Model: 794380--320 ❑Annular Space or Vault Sensor. Model: El Piping Sump/Trench Sensor(s). Model: 794380-350 171 Piping Sump/Trench Sensor(s). Model: [D Fill Sump Sensor(s). Model: 794380-350 [] Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: []Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: mechanical 1790091-001 [j Tank Overfill/High-Level Sensor. Model: Other(specify equipment t and model in Section E on Page 2).. []Other(specify equiEZent!XEe and model in Section E on Page 2). Tank ID: Tank IDT_ [I In-Tank Gauging Probe. Model: [I In-Tank Gauging Probe. Mode F-1 Annular Space or Vault Sensor. Model: 0 Annular Space or Vault Sensor. MZ 0 Piping Sump/Trench Sensor(s). Model: F]Piping Sump/Trench Sensor(s). Model: 171 Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model:R rl Mechanical Line Leak Detector. Model:1 ❑Mechanical Line Leak Detector. Mode 0 Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Modell []Tank Overfill/High-Level Sensor. Model: H Tank Overfill/High-Level Sensor. 1:1 C1 Other(specify 2quipment type and model in Section E on Page 2). rl Other(specify equipment type and model in Section E on P 2). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: I Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). H Shear Valve(s). Dispenser Containment Float(s)and Chain(s). Disgenser Containment Floats and Chain�s). Dispenser to: Dispenser 10: 0 Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: 171 Shear Valve(s). Shear Valve(s). 11 Disgenser Containment Floats and Chain�s). Dispenser Containment Floats)and Chains). DispenserID: Dispenser 10:— 17 Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: C1 Shear Valve(s). 0 Shear Valve(s). 0 Disg2nser Containment Float(s)and Chain(s I0 Disgenser 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 verity 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): E]System set-up EjAlarm history report Technician Name(print): David Smith Signature:David Smith 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:2016-08-03 Monitoring System Certification Page 1 of 4 12/07 QA/QC APPROVED 8/3/201612:27 PMBrandon B 1 2/21/07