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® ONI RING SYSTEM CERTIFI ATI00ECEV E 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 ChO Vf&#120ft This form must be used to document testing and servicing of monitoring equipment.A stearate certificaEt red for each monitoring,system control panel by the technician who performs the work. A copy of this form �e tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating U sys ems in 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 95206 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 3,2009 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates eciric equipment inspected/serviced: Tank ID: #1 JET FUEL Tank ID: El 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: Cl Fill Sump Sensor(s). Model:V/R 208 ❑ hill Sump Sensor(s). Model: ( )Mechanical Line Leak Detector. Model:N/A ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model:N/A ❑ Electronic Line Leak Detector. Model: 91 Tank Overfill/High-Level Sensor. Model: V/R ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment ry e 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: Ll 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(s eciff euipment type and model in Section E oil Page 2)_ Dispenser ID: Dispenser ID: O Dispenser Containment Sensor(s). Model: _ ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). ❑ Shear Valve(s). O 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). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Shear Va1ve(s). ❑ Shear Va!ve(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 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: Eric Jklocgaard 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 3,2009 Page 1 of 3 03/01