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• 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 #208117 Bldg. No.: Site Address: 755 S. TRACY BLVD City: TRACY Facility Contact Person: MGR - MARIA Contact Phone No.: 209-830-0370 Make/Model of Monitoring System: Veeder Root TLS -350 B. Inventory of Equipment Tested/Certified Check the annrnnriatp hmrpc to indiratp cnarifir pnninmant incnartad/carvirade Zip: 95376 Date of Testing/Servicing: 2/2/2018 Tank ID: T 1 - PREMIUM Tank ID: PF In -Tank Gauging Probe. Model: 846390-111 In -Tank Gauging Probe. Model: rV Annular Space or Vault Sensor. Model: 7943901109 Annular Space or Vault Sensor. Model: P Piping Sump / Trench Sensor(s). Model: 794380-208 Piping Sump / Trench Sensor(s). Model: P Fill Sump Sensor(s). Model: 794380-208 r Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: r Mechanical Line Leak Detector. Model: PF Electronic Line Leak Detector. Model: Veeder Root PLLD - r Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: flapper r Tank Overfill / High -Level Sensor. Model: Other(specify equipment a and model in Section E on Pa e 2). f Other(specify a ui ment type and model in Section E on Pae 2). Tank ID: T 2 - REGULAR Tank ID: P' In -Tank Gauging Probe. Model: 846390-111 In -Tank Gauging Probe. Model: rv_�' Annular Space or Vault Sensor. Model: 794390-409 Annular Space or Vault Sensor. Model: PPiping Sump / Trench Sensor(s). Model: 794380-208 Piping Sump / Trench Sensor(s). Model: Fill Sump Sensor(s). Model: 794380-208 Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: r Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Veeder Root PLLD - 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 Pa e 2). r Other(specify equipment a and model in Section E on Pacie 2). Dispenser 1/2 Dispenser 7/8 ID: ID: rV Dispenser Containment Sensor(s). Model: 794380-208 P7 Dispenser Containment Sensor(s). Model: 794380-208 r Shear Valve(s). rY7 Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser 3/4 Dispenser 9/10 ID: ID: Dispenser Containment Sensor(s). Model: 794380-208 P' Dispenser Containment Sensor(s). Model: 794380-208 r Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s) and Chain(s). r Dispenser Containment Float(s) and Chain(s). Dispenser 5/6 Dispenser 11/12 ID: ID: Dispenser Containment Sensor(s). Model: 794380-208 ry Dispenser Containment Sensor(s). Model: 794380-208 r Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). -IT Ene Tacmty contains more tames or aispensers, copy Ems toren. incivae mtormation Tor every tanK ana aispenser at the Tacmty. 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): R System set- up P Alarm history report Technician Name (print): Tim Elebeck Certification No.: B35252 Testing Company Name: Tanknology Signature: License. No.: 743160 Class'A' Testing Company Address: 11000 N. MoPac Expressway Suite 500 Monitoring System Certification Page 1 Phone No.: (800) 800-4633 Date of Testing/Servicing: 2/2/2018 12/07