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Appendix VI RECEYEDD MONITORING YSTEM CERTIFICATION MAY d 7 20i@For Use By All Jurisd ctions Within the State of California ) �R%j ,f flEA t TH Authority Cited: Chapter 6.7, Health and Safety Code; hapter 16, Division 3,Title 23, a �C�S Regulations /// �j This form must be used to document testing and servicing of monitoring equ pment.A separate certification or report must be prepared for each monitoring system control panel by the technician who performs thew irk 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 I cal agency regulating UST systems within 30 days of test date. A. General Information Facility Name: STOCKTON USD Bldg.No.: Site Address: 1032 EL DINA DR City: STOCKTON Zip: 95205 Facility Contact Person: BUTCH Contact Phone No.: (209)993-7045 Make/Model of Monitoring System: INCON 1001 Date of Testing/Servicing: 05-07-10 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: [TaTanklD: DIEging Probe. Model MAG ® In-Tank Gauging Probe. Model: MAG ce or Vault Sensor. Model: ELS ® Annular Space or Vault Sensor. Model: ELS /Trench Sensor(s). Model: ULS ® Piping Sump/Trench Sensor(s). Model: ULS nsor(s). Model: ULS ® Fill Sump Sensor(s). Model: ULS ® Mechanical Line Leak Detector. Model: PE PERTO ® Mechanical Line Leak Detector. Model: RED JACKET ❑ Electronic Line Leak Detector. Model: ❑ 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). Tank ID: Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model. ❑ 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: ❑ Electronic Line Leak Detector. Model: ❑ 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: 1-2 DIE Dispenser ID: 3-4 DIE ® Dispenser Containment Sensor(s) Model. ULS ® Dispenser Containment Sensor(s). Model: ULS ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s) ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID. 5-6 RUL Dispenser ID: ® Dispenser Containment Sensor(s). Model: ULS ❑ 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). Dispenser ID. Dispenser ID: ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: Sensor(s). Model: ❑ ShearValve(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.manufactur$rs'checklists)necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment.For any eq ipment capable of generating such reports,I have also attached a copy of the report;(check all that app4v): ❑System set-up Alarm history report Technician Name(print): Signature: 1, - /' . , Certification No.: 5273934-UT License No: 08-1740 -_- Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 2'0 STREET GALT,CA 95632 Date of Testing/Servicing: 05-07-10 Monitoring System Certification Page 1 of 4 2/21/07 S�LCN