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06/18/2013 11:35AN FAX 2093330318 RSH CORP Appendix VI MONITORING SYSTEM CERTIFICATION For flee By Ali Jurisdictions Within the State of Cal#pmisi Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, TMe 23, Califomia Code of Tfks term must be used to document testing and servicing of monitoring equipment. A separate certification, or report mist be prepared for each Monitoring system coftol panel IN the technician who Worms the wont. A copy of this form must be Provided to the tank system ownerioperater. The ownsNoperstor must Mibmlt s Copy of this form to the locos agency regulating UST systams vAthin 30 days of test daft. A. General information Facility Nano; COLLIER CIIEVRON Bldg. No.: Site Address: 25651 N HWY 99 City: ACAMPO zip: 45220 Facility COAW TONY Contact Phone No.: 1 S Pnftm- OI of MoAdtortng System: VERN! tt ROOT TLS -350 Data of TesbroServicing: 611112613 S, Inventory of Equipment Tested.Certified Check the worwriate boxes to indicate so& Tank ID: 87 Tank Site: I@ In -Tank Gauging Probe_ Model: MAC, I ® Annular Space or Vault Sensor, Model; 407 ® Piping Sump /Trench Sensorts). Model: 208 ® Fill Sump Sensor(s). Model: 208 ❑ Machanhcal Line Leak Detector. Model: ® Elaetronle Line Leek Detector. Model: PLLD ❑ Tank ovorn, w Hign-Lovei SBnsor. is ❑ Other (specify equipment type and model In Section E on Page 2). Tank 10: lair: Tank Size.: ® do -Tank Gauging Probe. Model: MACY 7 a Annular Spate or Vault Sensor. Model: 407 0 Pipmg Sump 1 Trench Smnw(s). I: 2011 ® Fill Sump Sensor(s), : 208 ® Mechanical line Look Detector. , ® Eladmic Uno Leak Detector. Model; PLLD ❑ Tank Overfill / High -Level Sensor, Model; 0 Other (Specify equipment type and mode( In Sem E on page 2), Dispenser ID: 111 Im Dispenser colywrvrwq Sensor(s), mow 208 I1 Shearvaluo(s). ❑ Dispenser Containment Flocks) and Chain(%), Dispenser ID; 516 Dispenser Containment Sensor(s). Model: 208 Shear Vaivs(s). C) Dispenser Containment Floats) and Chaln(s). Dispenser ID; 9110 ® Dispenser Carmta Ore nt Sensor(o). model; 208 ® St�rvalve(s). )� pispenasr Containment Flosks) and Chain(%), mote tanks or dispmnsers, copy this Tow Q 0002/0006 Tank ID; Tank Sire: ® In -Tank Gauging Probc. Model: 0 Annular Space or Vault Sensor, Model: IM Plphv Sump t Trench Sonsor{s). Model: ❑ Fill Sump SOnsor(s). Model: ❑ Mechanical Line Leak Datqotor. Model: ❑ Electronic line Leek Detector. Modal: ❑ TanK Overfill 1 High -Level Sensor. Modol: ❑ Other (specify equipment type and model in Section E on Page ?) Tank ID: 91 Tank Size: 0 In -Tank Gauging Probe. Model: MAG 1 0 Annular Space or Vault Sensor. modet; 407 ® Piping Sump / Trench Sensor(s), : 208, ..__ 0 Fill Sump Senscr(s). Model: 208 ❑ Mechanical line Leak Detector. Model: 0 Electronic Una Leak DoWW, Model: PLLD ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment We and modal in Soetion E on F61777, _ • ® Dispenser Containment Sensor(s). 0 Shear VaNe(s). ❑ Dispenser Containment Floats) and Chain(s), OispenserID: 7/8 ® wpanser Containment Sensor(s). Model: ® Shear Valve(s). ❑ Dispenses Corhtauhment Floats) and Chsin(s). Dii;pensor lD: 11112 ® Dispenser Containment Sensor(s). Model: 208 ® Shear VaNe(S). ❑ Dispenser Containment Flost(s) and ChAin(9). awry tank and dispenser at the raduty C. Certification , i cattify that Ste equipment Identified In this document was Insipactedisaryliced In accordance VAth the manufactufm, guidelines, AttachO 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 Monitorift oquipment. For any equipment capable of concreting such reports, i have also attached a dopy of the report felreck alllkar ): 0 System set-up ® Alarm history report Technician Nam (print): ZANE NIMMO CCrtlficatlon No.: Testing Company Name: AFFORDA-TEST Testing Company Addrvts: 446 2- STRE[T GALT, CA OM32 Mori toring System Certification Signature;' - License NO: 04-IWIS Phone No. (209)744-0143 Dale of TestinglServ=ng: 6/11/13 Page 1 of 4 2121/07