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we "® 't6:C�ej MONOORING SYSTEM CETI %ATI ®V 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, is Code of a lations ply This form must be used to document testing and servicing of monitoring equipment.A separate certit7 a mmared for each monitoring system control panel by the technician who performs the work. A copy of this form m ko the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST sys ' hin 30 days of test date. A. General Information Facility Name: Bank of Stockton Bldg.No.: Hanger 3 ". Site Address: 1941 Lockheed Court City: Stockton Zip 952 Facility Contact Person: Norm White Contact Phone No.: 209.483.0257 Make/Model of Monitoring System: Veeder-Root TLS-350 Date of Testing/Servicing: November 2,201`0 Q_ B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: #1 JET FUEL Tank ID: ®In-Tank Gauging Probe. Model:Mag Probe ❑ In-Tank Gauging Probe. Model: (x)Annular Space or Vault Sensor. Model:V/R 407 ❑ Annular Space or Vault Sensor. Model: (x)Piping Sump/Trench Sensor(s). Model:V/R 208 _❑ Piping Sump/Trench Sensor(s). Model: Fiii Sump Sensor(s). Model:V/R 208 ❑ Fill Sump Sensor(s). Model: ( )Mechanical Line Leak Detector. Model:N/A ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Mopel:N/A ❑ Electronic Line Leak Detector. Model: ®Tank Overfill/High-Level Sensor. Model: V/R. O PW VALVk. ❑ Tank Overfill/High-Level Sensor. Model: ❑ Others eci equipment a and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). TRANS SUMP 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/Iligh-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). ❑ cifza ui ment a and model in Section E on Page 2). 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). ❑ Dis enser Containment Floats 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). ❑ Dis enser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: O Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). ^ S.:ewr Valae (s). N ❑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 themanufacturers' 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): ()System set-up (X)Alarm history report !' Technician Name(print): Eric Molgaard Signature.: Certification No.: VR A27995 License No.: 309105 Testing Company Name:STOCKTON SERVICE STATION EQUIPMENT CO. INC. Phone No 209-464-8333 Site Address: 1941 Lockheed Court Date of Testing/Servicing: November 2,2010 Pagel of 3 03/01 Monitoring System Certification