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A. Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.waterboards.ca.gov.) 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 UST systems within 30 days of test date. General Information Manteca CA FO REGEN Facility Name: Bldg. No.: MANTCA Site Address: 2551 E. Louise Ave., Lathrop, CA 95330 Facility Contact Person: Jonathan Pakele Contact Phone No.: (916) 439-6048 Make/Model of Monitoring System: Pneumercator Date of Testing/Servicing: 4/18/2018 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: MANTECA/Diesel/600 Tank ID: Q In -Tank Gauging Probe. Model: MP400 ❑ In -Tank Gauging Probe. Model: Q Annular Space or Vault Sensor. Model: LS610 ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: LS600 ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ 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: Q Tank Overfill / High -Level Sensor. Model: MechanicaliRA200 ❑ Tank Overfill / High -Level Sensor. Model: Q Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment t and model in Section E on Page 2). TanklD: TankiD: ❑ 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 Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ FII 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: El Other (specify ui ment lype and model in Section E on Page 2). Other (specify equipment t and model in Section E on Page 2 . Dispenser ID: _ Dispenser ID: .................. ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). Shear Valve(s). ❑ Dispenser Containment Floats and Chains . Dispenser 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 Floats and Chain(s). Dispenser Containment Floats and Chain s . Dispenser 10: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model:❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chains ❑ Dispenser Containment Floats and Chains . "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 apply): [System set-up QAlarm history report Technician Name (print): Kraig Kinder Certification No.: 8296393 Signature: Kraig Kinder Testing Company Name:. SunWest Engineering Const., Inc. Testing Company Address: 4780 Cheyenne Way, Chino, CA 91710 Monitoring System Certification License. No.: Page 1 of 4 Digitally signed by Kraig Kinder Date: 2018.04.18 11:67:21 -07'00' Phone No.: (888)588-8737 Date of Testing/Servicing: 4/18/2018 12/07 QA/QC APPROVED 4/19/20189=15AMTeresa Ant 1 2/21/07