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RECEIVEL) ",� 10 1 -i ,,l i -I 5 Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http:w Wto40N"NTP MONITORING STCERTIFICATION For Use By All Jurisdictions Within the State of Califomia 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: Tulare Farms, LLLC. Bldg. No.: Site Address: 2771 E French Camp Rd city: Manteca Zip: 95336 Facility Contact Person: Michael Edgar Contact Phone No.:2( 09 ) 235-3055 Date of Testing/Servicing: 6 / 5 / 2 0 1 4 B. Inventory of Equipment Tested/Certified 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 >Warm history report Technician Name (print): Carl Wayne Henderson Signature: `^� - Certification No.: 5252923 ICC License. No.: A25001 GVR Testing Company Name: HMC - Henderson Maint Co Phone No.: 2( 09 ) 467-7573 Testing Company Address: PCO Box 31325 - Stockton, CA 95213 Date of Testing/Servicing: 6 / 5 / 2 0 1 4 Monitoring System Corti If.CEINIED t j r:. , Page f of 4 12/07 RECEIVED ENVIRONMENTAL , HEALTH DEPARTMENT