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Appendix V1 2 Oj (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at htt0twwwWaterboards.ca.gov.) MONITORING SYSTEM CERTIFICATION ENVi ' y. For Use By AM Judsdictions Within the State of California Authority Cited:Chapter 6.7,Health and Safety Code;Chapter 16,Division 3, Title 23,California Code of Regulations This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be prepared 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 regu lating UST systems within 30 days of test date. A. General information Facility Name: Kaiser Stockton Bldg.No.: Site Address: 7373 West Lane City:Stockton Zip- 96210 Facility Contact Person: Contact Phone No.: Make/Model of Monitoring System: Veeder-Root TLS-350 Date of TestingraWcIng: 612812017 B. Inventory of Equipment Tested/Certified Chock the appropriate boxes to Indicates peelf Ic equipment Ins l ected/serviced; Tank-ID: TI DSL TankID: !e In-Tank Gauging Probe. Model:MXG-Plul—s — In-Tank Gauging Probe. Model: Ig Annular Space or Vault Sensor. Model:794390-409 larit Sensor. Model: je Piping Sump/Trench Sensor(s). Model:794380-208 pr,4 Surma Sensor(s). Model: — Fill Sump Sensor(s). Model: I Sump Model: — Mechanical Line Leak Detector. Model: Medianical Line Leak Detector. Model: — Electronic Line Leak Detector. Model: — Electronic Line Leak Detector. Model; Tank Overfill/I-Ilgh-Level Sensor. Model:FlaDper — Tank Overfill/I-Ilgh-Level Sensor. Model: Others 9902Ment and model in Section E 21Page 2). LJ Other(!pec!!y 2MiEent to and model In Section E on PaLe TankID: 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: FIR Sump Sensor(s). Model: — Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: — Mechank mi Line Leak Detector. Model: Electronic Line Leak Detector. Model: — Electronic Line Leak Detector. Model: Lj Tank Overfill/High-Levet Sensor. Model: —Tank Overfill/High-Level Sensor. Model: others 29ulEMent and model In Section E on P 21. LJ.2her.fu&2SUIEMent Dispenser 10: popenser 10: Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). Disi)enser Containment Float(s)and Chaln(s). 2!s enser Containment Floats�and Chains). Dispenser I D: DisDanser ID: 8 Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). Dispenser Containment F122M and Chains l J UsEenser Containment Floats and Chains Dispenser ID: Dimenser ID: Rep's - Dispenser Containment Sensoqs). Model: I I Dispenser Containment Sensor(s). Model: Shear hear Valve(s). Shear Valve(s) D is ispenser Containment Floats and Chaln(s DisEensar Containment Float(s)and Chain(s). t t 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 inspectedfasiviced In accordance with the manufacturers' guidelines. Attached to this Certification Is Information(s.g.manufacturers'checklists)necessary to verify that this Information Is correct and a Plot Plan showing the layout of monitorl!!p equipment. For any equipment capable of generating such reports,I have also attached a copy of the report;(check all that apply). Wjsyetemsat-up Pj Alarm history report Technician Nam(print): David Walker Signature: — j-� 40 Certification No.: A32030 License.No.: 808313 Testing Company Name: Belshire Environmental Services, Inc. — Phone No.:( 949 )460-6200 Testing Company Address: 25971 Towne Contra Dr.,Foothill Ranch,CA 92610 Date of Testing/Servicing: 6128/2017 Monitoring System Certification Page 1 of 4 12107