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� M RECEIVED APR 2 32017 - Appendix V1 HEAM, (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at httD://wwvv,!JM=== 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 REGENBldNo.: MANTCA Facility Name: Bldg. 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: Pnuemicator TMS 2000 Date of Testing/Servicing: 4/19/2017 B. Inventory of Equipment Tested/Certified Check the aoDroDriate boxes to indicate soecific equipment inspected/servicedA. Tank ID: MANTECA I Diesel 1500 gallm Tank ID: In -Tank Gauging Probe. Model: mp450 0 In -Tank Gauging Probe. Model: . . . .. . ............ .... . . Annular Space or Vault Sensor. Model: 1:s610 [I Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: LS 600 171 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: . ... .... ..... ............. . ... 0 Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill I High -Level Sensor. Model: _MechaWical.fiapper I RA200 Q Tank Overfill / High -Level Sensor. Model: Other (specify equiMent t and model Other (sEci!X equipment!ype and model in Section E on Page 2). Tank ID: Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: Q Annular Space or Vault Sensor. Model: • Piping Sump! Trench Sensor(s). Model: ❑ Piping Sump /Trench Sensor(s). Model: • Fill Sump Sensor(s). Model: Q Fill Sump Sensor(s). Model: . ... . .. . .. ................. . .... ................ . ....... . .... 0 Mechanical Line Leak Detector. Model:anical Line Leak Detector. MElechtmnic Model: 0 Electronic Line Leak Detector. Model: Line Leak Detector. Model: .. ........... ............. 0 Tank Overfill / High -Level Sensor. Model: Tank Overfill / High -Level Sensor. Model: 0 Other (specify eguipment type and model in Section E on rj Other (specify equipment t and model in Section E on P e 2 Dispenser ID: Dispenser ID: [I Dispenser Containment Sensor(s). Model: Q Dispenser Containment Sensor(s). Model: 0 Shear Valve(s. Shear Vatve.s I ). 0 Dispenser Containment Floats ) and Dispenser Containment Floats and Chainis). Dispenser ID: Dispenser ID: 0 Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). ❑ Shear Valve(s). 0 Dispenser Containment Float(s) and Chain�sj. Dispenser Containment Floats j and Chajn�s). DispenserID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: I Dispenser Containment Sensor(s). Model: ❑ Shear VaJve(s). I Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s Dis2enser 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 verity 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): El System set-up n -Alarm history report Technician Name (print). David Smith Signature: David Smith -------- . . ............ Certification No.: 8260473 License. No.: 703190 Testing Company Name; SunWest Engineering Const., Inc. Testing Company Address: 4780 Cheyenne Way, Chino, CA 91710 Monitoring System Certification QA/QC APPROVED 4/20/20179:26AMBrandon Bo Page 1 of 4 Phone No.: 888-588-8737 Date of Testing/Servicing: 4/1912017 12/07 2/21/07