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o- • Appendix VI • (Copies or Monitoring System Certification form and UST Monitoring Not Plan available athttp;//wwwswrb.ca.eoy,) MONITORING SYSTEM CERTIFICATION ror Use By All Jurisdictlons Within the Stale of California AIM rority Cited. Chapter&7, fleahh and Safety Cdde;Chapter 16,Division 3, Title 23,California Code of Regulations This form'must ba used to decumc11L testing and servicing of monitoring equipment.l . ml must he tc cication or the repornk t muststenn be pre pored o r Quch The monitoring aystom control by the technician who performs the work. A copyprovided owner/operatnr must submit a cagy of this form to the local agency regulating US-T systems within 30 days of Inst date. A. General Information Facility Name: San Joaquin RTD Bldg,No.: Site Address: 1533 I;. Lindsay St. City: Stockton lip 95205 Facility Contact Person: Doug Smith Contact Phone No.: 209.945.5566 Make/Model of Monitoring System: INCON 2001 Date of Testing/Servicing: June 30,2010 B. Inventory of Equipment Tested/Certified Check the appropriote holes toindieate s ucifiee ui ment Ing reted/serviced: Tonic ID; #1 Tank ID:03 In-Tank Gauging Probe. Model: ,._ 17 In-Tank Gauging Probe. Model:_ (x)Annular Space or Vault Sensor. Model:TSP-HTS Gd Annular Space or Vault Sensor. Model:TSP-HfS (t)Piping Sump/Trench Scnsor(s). Model:TSP-ULS O Piping Sump/'trench Sensar(s). Model:TSP-ULS El pill Sump Scnsor(s). Model: _ ❑ Fill Sump Sensor(s). Model: ,...— ( )Mechanical Line Look Detector. Model: ❑ Mechanical Linc l,eak Detector. Model: ❑ Electronic Line Leak Detector. Model: __ ❑ Blccuenic Line Look Detector. Model 0 Tank Overfill/High-Lcvcl Sensor. Mode(: O Tank Overfill/I ligh-Lovel Sensor. Model: n Others cmc ui mcnt a and model in Section E on Pa a 2). d� Other s cele c ui mcnt typo and model in Seclion r an Pa&c 2). Tonic ID: #2 'Dank ID:#4 ( )In=Tank Gauging Probe, Model:_ 0 In-Tank Gauging Probe. Model' As Annulnr Space or Vault Sensor. Model:TSP-Ii IS 0 Annular Space or Vault Sensor, Model:TSP-HTS m Piping Sump/'hrench SL`naor(a), Model:TSP-ULS 0 Piping Sump/Trench Scnsor(s). Model TSP-ULS 0 Fill Sump Somor(s). Model ❑ Fill Sump Sensor(s). Model:_ M I Mechanical Linc Look Detector, Model'FE PETRO IM Mechanical Line Look Detector. Model: Flt PETRO C] ricelronic Line I,cak Detector. Model: _ 0 P.lactronic Linc Leak Detector. Model; L] Took Overfill;FI1gh4.evcl Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: _ ❑ Other s ecif equipment c and model in Section E on P e 2 . Q Other s eci c ui ment c and model in Section E on Page 2 . DIapenser ID:#I .Dispenser ID;#2 O Dispenser Containment Sensor(s). Model; TSP-ULS IZI Dispenser Containment Sensor(s). Model:'rSP-ULS Shear Valve(s). 0 Shear Valve(s). _ Dispenser Contalamont ploat(s)and Chain(s). ❑ Dispenser Containment Float(s) and Chains . Dispenser ID: 43 Dispenser ID: Dispenser Containment Sensor(s). Model: TSP-ULS CI Dispenser Containmcnl Sensor(s), Model SheorVnlve(sL 0 Shear Valve(s). ❑ Di s cnscr COnminment Float s and Chains . 0 Uispvnsur Containment Floats)and Chain(s). Dispenser 11): Dispenser -._.- 11 Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model:.___ Shcnr Vnlvc(sl. ❑ Shear Valve(s). ❑Dis cnscr CpLnimnent Flual s and Chains ❑ Dispenser Containment Floats and ChLlin s . •Ir the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility C. Certification - 1 certify that the equipment identified in this document was inspected/serviced In accordance with the manufacturers' gui(lolines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot PIM showing the Inynut of monitoring equipment. For any equipment capable of generating such reports.I have also attached a copy of the report;(Check all thnr apply): ( )System set-up ( )Alarm history report 'I'cehnlaian Name(print); Eric Molgaard Signature: Eti.e ,MoigaaTd Certification No.: ICC California UST ServiceTech#9250200d)T license Nn.: 309105 'resting Company Name;STOCKTON SERVICE STATION EQUIPMENT CO.INC. Phone No 209464.5333 'testing Company Address; 905 N.Union Street,Stockton,CA 95205-4152 Dalc of Tcsting/Servicing: June 30.2010 Monitoring system certificallon rage 1 of 4 12107