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Appendix V1 (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at httD:;"www.waterboards.0a.clov.) 7W 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 Manteca CO aMNTCCAXG82A Bld .No.: Facility Name: - Site Address: 430 W.Center Street,Manteca,CA 95336 Facility Contact Person: Walley Riggs Contact Phone No.: (209)239-0251 Make!'Model of Monitoring System: VEEDER ROOT TLS-350 Date of Testing/Servicing:8/24/2017 B. Inventory of Equipment Tested/Certified Check the aperopriate boxes to indicate seecific equipment ins ected/serviced, Tank ID: TG013935-DIESEL-6,000 GAL, Tank to: r7l In-Tank Gauging Probe. Model:___ 0 In-Tank Gauging Probe. Model: 0 Annular Space or Vault Sensor. Model: :1 Annular Space or Vau it Sensor. Model: [I Piping Sump/Trench Sensor(s). Moclel:, ❑I Piping Sump/Trench Sensor(s). Model: []Fill Sump Sensor(s). Model: 0 Fill Sump Sensor(s). Model C]mechanical Line Leak Detector. Model: ............ E]Mechanical Line Leak Detector. Model: ................. 171 Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: 0 Tank Overfill/High-Level Sensor. Model: Q Tank Overfill i High-Level Sensor. Model: E]Other(specify equipment t and model in Section E on Page 2). Q Other(sLecify equipment t and model in Section E on Pa 2). TankID: TankID: El In-Tank Gauging Probe. Model: In-Tank Gauging Probe. Model F-1 Annular Space or Vault Sensor. Model: Q Annular Space or Vault Sensor. Model: El Piping Sump iTrench Sensor(s). Model: ❑Piping Sump/Trench Sensor(s). Model: 0 Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model:........_.... 17 Mechanical Line Leak Detector. Model: El Mechanical Line Leak Detector. Model: M Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model C]Tank Overfill 11 High-Level Sensor. Model: Tank Overfill/High-Level Sensor. Model: Other(specifX 2quiaent type and model in Section Eon I- Other isDecify eguipment type and model in Section E on Page 2). Dispenser ID- Dispenser ID: C1 Dispenser Containment Sonsor(s). Model: r7l Dispenser Containment Sensor(s). Model: C3 Shear Valvels). Shear Valve(s). 0 Dispenser Containment Float(s)and Clhain�s). 8 Dispenser Containment Floats)and Chain(s). Dispenser ID:_ .......... Dispenser ID: El Dispenser Containment Sensor(s). —Model: 0 Dispenser Containment Sensor(s). Model ❑ Shear Valve(s). C3 Shear Valve(s). Dis2enser Containment Floats)and Chain�s). Dis22,nser Containment Floats)and Chain(s), DispenserID:_ Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). Q Shear Valve(s). ❑ dispenser Containment Float(s)and 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 inspected1serviced 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): BSystem set-up EjAlarrn history report Technician Name(print): Leonardo Aguilar Signature:Leonardo Aguilar ............................. ......................... Certification No.: 5302718-UT License.No.: 703190 i es'ing Company Name: SunWest Engineering Const.,Inc. Phone No.:888-588-8737 Testing Company Address: 4780 Cheyenne Way,Chino,CA 91710 Date of Testing/Servicing:812412017 Monitoring System Certification Page I of 4 12/07 QA/QC APPROVED 8/25/201712:04 PMBrandon B 2/21/07