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Appendix VI '00 MONITORING SYSTEM CERTIFICATION ° °-"�°)'° For Use By All Jurisdictions Within the State of California - / I • , Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Cade 0f` ! ` (`i 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 M. -COLLIER RD, CHEVRON Bldg. No.: Site Arihiracc 25651 N. HWY 99 City: ACAMPO Zip: 95220 Facility Contact Parcnn• TONY Contact Phone No.: (209) 333.1740 Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 6/15/2010 B. Inventory of Equipment Tested/Certified Check the an ro riate boxes to indicate specific equipment inspected/serviced: Tank ID: 87 Tank Size: 12 K Tank ID: Tank Size: ❑ In -Tank Gauging Probe. Model: ® In -Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 407 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump / Trench Sensor(s). Model: 208 ❑ Piping Sump / Trench Sensor(s). Model: ® Fill Sump Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: (D Electronic Line Leak Detector, Model: PLLD - ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: DIE Tank Size: 12 K Tank ID: 91 Tank Size: 12 K ® In -Tank Gauging Probe. Model: MAG 1 ® In -Tank Gauging Probe. Model: MAG 7 ® Annular Space or Vault Sensor, Model: 407 ® Annular Space or Vault Sensor. Model: 407 ® Piping Sump / Trench Sensor(s). Model: 208 ® Piping Sump / Trench Sensor(s). Model: 208 ® Fill Sump Sensor(s). Model: 208 ® Fill Sump Sensor(s). Model: 208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: PLLD ® Electronic Line Leak Detector. Model: PLLD ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: 1/2 Dispenser ID: 3/4 ® Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model: 208 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5/6 Dispenser ID: 7/8 ® Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model: 208 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 9/10 Dispenser ID: 11/12 ® Dispenser Containment ® Dispenser Containment Sensor(s). Model: 208 Sensor(s). Model: 208 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ 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 appt)q: ® System set-up ® Alarm history report Technician Name (print): ZANE A NIMMO Signature: Certification No.: A28446 License No: 04-1676 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 _ Testing Company Address: 416 2 STREET GALT, CA 95632 Date of Testing/Servicing: 6/15/10 Monitoring System Certification Page 1 of 4 2/21/07