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E C E F REE D Appendix VI MONITORING SYSTEM CERTIFICATION OCT 15 2018 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 C�cde pMe%llta,�tiiolnls This form must be used to document testing and servicing of monitoring equipment.A separate certification or report muustVbee pre pareldd To'MENTAL I"j�ALTH each monitoring system control panel by the technician who performs the work.A copy of this form must be provided to the tank IRARTMDJ 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: WEST LANE CHEVRON Bldg.No.: Site Address: 4747 N. WEST LANE city: STOCKTON zip: 95210 Facility Contact Person: Contact Phone No.: ( ) Make/Model of Monitoring System: VEEDER ROOT TLS-350 Date of Testing/Servicing: 9/19/2018 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: 87 OCT Tank Size: 12 K Tank ID: 91 OCT Tank Size: 12 K N In-Tank Gauging Probe. Model: M A G 1 N In-Tank Gauging Probe. Model: M A G 1 ID Annular Space or Vault Sensor. Model: 4 0 9 N Annular Space or Vault Sensor. Model: 4 0 9 N Piping Sump/Trench Sensor(s). Model: 2 0 8 N Piping Sump/Trench Sensor(s). Model: 2 0 8 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: N Electronic Line Leak Detector. Model: P L L D - 8 4 8 4 N Electronic Line Leak Detector. Model: P L L D - 8 4 8 4 ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). Tank ID: 87 OCT- 2 Tank Size: 12K Tank ID: Tank Size: N In-Tank Gauging Probe. Model: M A G 1 ❑ In-Tank Gauging Probe. Model: N Annular Space or Vault Sensor. Model: 4 0 9 ❑ Annular Space or Vault Sensor. Model: N Piping Sump/Trench Sensor(s). Model: 2 0 8 ❑ 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: N Electronic Line Leak Detector. Model: P L L D - 8 4 8 4 ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). Dispenser ID: I / 2 Dispenser ID: 3 / 4 N Dispenser Containment Sensor(s). Model: 2 0 8 N Dispenser Containment Sensor(s). Model: 2 0 8 N Shear Valve(s). N Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5 / 6 Dispenser ID: 7 / 8 N Dispenser Containment Sensor(s). Model: 2 0 8 N Dispenser Containment Sensor(s). Model: 2 0 8 N Shear Valve(s). N Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)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 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): N System set-up ®Alarm history report Technician Name(print): ZANE NIMMO Signature: Certification No.: A28446 License No: 04-1676 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0112 Testing Company Address: 416 2nd STREET GALT,CA 95632 Date of Testing/Servicing: 9/19/2018 Monitoring System Certification Page 1 of 4 2/21/07