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MONARING SYSTEM CERTIFNATION DEC 01 ;008 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 Cp This form must be used to document testing and servicing of monitoring equipment.A separate certification or r'�b'�' for each monitoring system control panel by the technician who performs the work. 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 local agency regulating UST systems within 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 7,2008 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates ecific equipment inspected/serviced: Tank ID: #1 JET FUEL Tank ID: MI In-Tank Gauging Probe. Model:Mag Probe El In-Tank Gauging Probe. Model: (x)Annular Space or Vault Sensor. Model:V/R 407 0 Annular Space or Vault Sensor. Model: (X)Piping Sump/Trench Sensor(s). Model:VIR 208 El Piping Sump/Trench Sensor(s). Model: El Fill Sump Sensor(s). Model:VIR 208 LJ FiL' Sump Sensor(s). Model: ( )Mechanical Line Leak Detector. Model:N/A U Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model:N/A El Electronic Line Leak Detector. Model: El Tank Overfill/High-Level Sensor. Model: VIR 0 Tank Overfill/High-Level Sensor. Model: E3 Other(specia equipment type and model in Section E on Page 2). U Other(specify equipment type and model in Section E on Page 2). TRANS SUMP Tank ID: )In-Tank Gauging Probe. Model: E3 In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 0 Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: E3 Piping Sump/Trench Sensor(s). Model: U Fill Sump Sensor(s). Model: E3 Fill Sump Sensor(s). Model: E3 Mechanical Line Leak Detector. Model: El Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: LI Electronic Line Leak Detector. Model: Ll Tank Overfill/High-Level Sensor. Model: Q Tank Overfill/High-Level Sensor. Model: U Other(specify equipment type and model in Section E on Page 2). 1 E3 Other(sgecify equipment type and model in Section E on Page 2). Dispenser ID: Dispenser ID: Dispenser Containment Sensor(s). Model: Ll Dispenser Containment Sensor(s). Model: Shear Valve(s). Ll Shear Valve(s). )Dispenser Containment Float(s)and Chain(s). U Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model: Shear Valve(s). Q Shear Valve(s). El Dispenser Containment Float(s)and Chain(s). Ll Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: E3 Dispenser Containment Sensor(s). Model: U Dispenser Containment Sensor(s). Model: Shear Valve(s). L! S11'ar V2M:(s). E313ispenser Containment Float(s)and Chain(s). L3 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 them an ufactu rers' 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): Mike Jones Signature.: Niree Jones Certification No.: VR A25924 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 7,2008 Page 1 of 3 03/01