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• Appendix VI (Copics of Monitoring System Certification form and UST Monitoring Plot Plan available at hun.//wwwswrb;ea<.anv) MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the 51ale of California Authority Cited,Chapter 6.7,Health and Safety Code, Chapter 16, Division 3, Title 23, Californi r Code of Regetlations This form must he used to document testing and servicing of monitoring equipmcni. A separate certification or report must be prepared for each monitoring system control by the technician who performs the work. A copy of this Tarin must be provided to the tank system owncr/operator. 'ncc owner/operator mast submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: Snn,loaquin RTA Bldg.No.: Site Address: 1533 T. Lindsay St. City: Stockton Zip 9520.5 Facility Contact Person: Doug Smith Contact Phone No.: 209.948.5566 Make/Model of Monitoring System: INCON 2001 Datc orTesting/Servicing: A=30,20110 S. Inventory of Equipment Tested/Certified Check the n ro rinte boxes to indicantspecific c ni rent ins,Cored/serviced: Tank ID: 05 ATP Tank ID:#6 GAS In-Tank Gauging Probe Model:_ Q in-Tank Gouging Probe. Model; (x)Annular Space or Vault Scnsur. Model:TSP-TITS ®Annuinr Space or Vault Sensor. Model:TSP-HIS (x)PIping Sump/'Trench Sensor(s). Model:TSP-ULS CKI Piping Sump/Trench Sensor(s). Model:TSP-ULS U Pill Sump Sensnr(s). Model: Q Fill Sump Scnsor(s). Model; (x)Mcchanicnl Line Leak Detector, Model: ._ MI Mechanical Linc Leak Detector. Model: Fc-Petro STP-MLD ❑ Noctronic Line Lask Dcleatn•. Modeh U Electronic Linc Leak Detector. Model: ❑ THnk Overfill/14igh4.evcl Sensor. Model: U Tank Ovcrlill/High-Level Sensor. Model; U Other s ecif cul Ment c and model In Section E on Pa c Z . ❑ Other spccifequipment type and model in Seetion R on Pse 2). Tank ID: #7 WASTE OIL Tank TD:48 ( )In=I'HnkGauging Probe. Model:_ Q fn-rank Gauging Probe. Model: S Annular Space or Vault Sensor. Model: TSP-HIS ®Annuhu•Space or Vault Sensor, Model:TSP-HIS F2 I'ipingSump/'I'tench 9ensor(H). Model:TSP-UIS Cl Piping Sump/Trench Scnsor(s). Model:TSP-UI,S U Fill Sump Sensor(s). Model: _ U Fill Sump Senscr(s)• Model Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: W Electronic Linc beak Detector, Model:_.._ _ U Electronic Linc Leak Detector. Model: _- Q Tank Overfill/High-bevel Sensor. Model: U Tank Overfill/I Iiglt-Level Sensor, Model: U Other s ccir.cquipmctlttkpe and model in Section R on Pa c 2 . U Others ecif c(ui ment a and model in Section E on Pae 2). Dispenser ID:9 Dispenser ID:k O Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s), Model: Shear Valve(s), U Shear Valvc(s). ( )Dispenser Conlaidment Floats find Chains , ❑ Dispenser Containment Floats and Chain (s). Dispenser ID: fl Dispenser ID: .._ _....__ 1)isrycnser(:nntainmcnt Sensor(s). Model: ❑ Dispenser Containment Sonsor(s). Mndcl: Shcar Vslve(s). U Shenr Velvets). U Dispenser Containment Floats and Chains . U bis cnscr Containment Floats)and Chain(s). Dispenser TD; Dispenser ID: - A Dispenser Containment Sensor(s). Model: U Dispenser Containment Scnsor(s). Model: Shear Vnlve(s). U Shear Valvc(s). UDis ensot Containment Firings)and Chains . Q Dispenser Containment FloatW and Chain (s). +If the facility contains more tanks or dispensers,copy this form. Include information Cur every tank and dispenser at the facility C. Certification -1 certify that the equipment Identified in this document was inspected/serviced in nccordnnec with the mnmdacturers' guidelines. Attnehed 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 cape ble of generating such reports,I have also nttached a copy of the report;(check at/that apply): O System set-up ( )Alarm history report Technician Name(print): Eric Molgnard Signature: 2i•rie- lotgaard Certification Na:ICC California LIST Scrvicc Tcch#5250200-UT License No.: 309105 Testing(lompany Name,STOCKTON SERVICE STATION EQUIPMENT CO.INC. Phone No 209-464-3333 Testing Company Address: 808 N.Union Street,Stockton,CA 95205.41.52 Data urTesting/Scrvicing, Jame 30,2010 Monlmring Synant Certification Page 2 or 12/07