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� t Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.swrcb.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. A.General Information Facility Name: CHEVRON#96171(N-621-1-3) Bldg. No.: 96171 Site Address: 6633 PACIFIC AVE City: STOCKTON Zip: 95207 Facility Contact Person: MGR-SUE LYNN Contact Phone No.: 477-4294 Make/Model of Monitoring System: Veeder Root TLS350 Date of Testing/Servicing: 1/6/2012 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment ins ected serviced: Tank ID: supreme-SUPREME Tank ID: regular 1-REGULAR 1 In-Tank Gauging Probe. Model: mag 17 In-Tank Gauging Probe. Model: mag r Annular Space or Vault Sensor. Model: 407 r Annular Space or Vault Sensor. Model: 407 Piping Sump/Trench Sensor(s). Model: 208 rV_ Piping Sump/Trench Sensor(s). Model: 208 W 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: Veeder Root PLLD Electronic Line Leak Detector. Model: Veeder Root PLLD Tank Overfill/High-Level Sensor.Model: flapper rV Tank Overfill/High-Level Sensor.Model: flapper Other(specify equipment a and model in Section E on Pa e 2). Other(specify equipment a and model in Section E on Pae 2). Tank ID: regular 2-REGULAR Tank ID: r In-Tank Gauging Probe. Model: mag rIn-Tank Gauging Probe. Model: r Annular Space or Vault Sensor. Model: 407 r Annular Space or Vault Sensor. Model: 170 Piping Sump/Trench Sensor(s). Model: 208 r Piping Sump/Trench Sensor(s). Model: W Fill Sump Sensor(s). Model: 208 F Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: r Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor.Model: flapper ( Tank Overfill/High-Level Sensor.Model: Other(specify equipment a and model in Section E on Page 2). Other(specify equipment a and model in Section E on Pae 2). Dispenser 1/2 Dispenser 3/4 ID: ID: 170 Dispenser Containment Sensor(s).Model: 208 Dispenser Containment Sensor(s).Model: 208 Shear Valve(s). T7 Shear Valve(s). Dispenser Containment Float(s)and Chain(s). 17 Dispenser Containment Float(s)and Chain(s). Dispenser 5j6 Dispenser 7/8 ID: ID. Dispenser Containment Sensor(s).Model: 208 Dispenser Containment Sensor(s).Model: 208 Shear Valve(s). rv— Shear Valve(s). r— Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser 9/10 Dispenser 11/12 ID: ID: Dispenser Containment Sensor(s).Model: 208 r Dispenser Containment Sensor(s).Model: 208 W Shear Valve(s). P Shear Valve(s). r— 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 apply): System set- up r Alarm history report Technician Name(print): Steven Willems Signature: ko Na. Certification No.: 836743 License.No.: 743160 Class'A' Testing Company Name: Tanknology Phone No.: (800)800-4633 Testing Company Address: 11000 N.MoPac Expressway Suite 500 Date of Testing/Servicing: 1/6/2012 Monitoring System Certification Page 1 of 3 12/07