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ORECEIVEL, 150710-349 Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at AN NfUSTI: 131 For Use By All Jurisdictions Within the State of Califomia 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: Manteca CO BIij. No.: CA4784419 Site Address: 430 W. Center Street City: Manteca Zip: 95336 Facility Contact Person: Vincent Scheaffer Contact Phone No.: 209-401-4547 Make/Model of Monitoring System: Veederoot TLS 350 Date of Testing/Servicing: 8®4-2015 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates ecific equipment ins cted/serviced: Tank ID: TG013935:dieseli6000 gallon Tank ID: In -Tank Gauging Probe. Model 847390-107 ❑ In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 794380-320 ❑ Annular Space or Vault Sensor. Model: 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 tine Leak Detector. Model: ❑ Electronic tine Leak Detector. Model: o; Tank Overfill / High -Level Sensor. Model: 790091-00I ❑ Tank Overfill I High -Level Sensor, Model: Other (specify a ui ent t)2e and model in Section E on Pa 2). ❑ Other (se2cify equipment type and model in Section E on Pa 2). Tank ID: Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensors). Model: ❑ Piping Sump/ Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: 13 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: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment a and model in Section E on Pace 21. ❑ Others ci ui mens a and model in Section E on Pa 2). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). 13 Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). 13 Dispenser Containment Floats and Chain(s). Dispenser ID: Dispenser ID: 0 Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Vahre(s). 13Dispenser Containment Floats and Chain(s). 13Dispenser Containment Floats 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 Float(sand Chains ❑Dis eraser Containment Floatisl 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 Piot Plan showing the layout of monitoring equipment For any equipment capable ofenerating such reports, I have also attached a copy of the report, (checkall that apply): ❑ System set-up � Alarm history repQrtpigifa lysigoed by Smifh David for WT 1Ri10 349 Technician Name (print): David Smith Signature: 0810412015 14:59:46 Certification No.: 8260473 License. No.: 703190 Testing Company Name: SunWest Engineering Phone No.: 8( 88 ) 588-8737 Testing Company Address: 4780 Cheyenne way Chino Ca.91710 Date of Testing/Servicing: 8_4-2015 Monitoring System Certification Page 1 of 4 12107 QA/QC APPROVED 8/26/20159:23 AMJustin Tre 2/21/07