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RA"GEWED MONITOUNG SYSTEM CERTIFI&TION For Use Bv All Jurisdictions Within the State of California APR 2 2 2013 Authority Cite& Chapter 67, 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 se to certification or renort monitoring Ustem control panel by the technician who performs the work. A copy of this form must be provided r-OWI&ARWOW 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: City Of Stockton Corp Yard Bldg. No.: Site Address: 1465 S Lincoln St City: Stockton Zip: 95206 Facility Contact Person: Contact Phone No.: Make/Model of Monitoring System: TLS -MO Date of Testing/Servicing: 4/18/2013 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment ins serviced: Tank ID: Diesel Tank iD- Regular 87 0 In -Tank Gauging Probe. Model: 846390-107 0 In -Tank Gauging Probe. Model: 946390-107 Annular Space or Vault Sensor. Model: 303 0 Annular Space or Vault Sensor. Model: 303 Piping Sump / Trench Sensor(s). Model: 208 0 Piping Sump / Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: n Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: [I Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: [I Electronic Line Leak Detector. Model: ❑ Tank Overfill I High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ED Other (specify equipment type and model in Section E on Page Other (specify equipment type and model in Section E on Page 2). Tank ID: Tank ID: [I In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe Model: [I Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: n Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: [I Fill Sump Sensor(s). Model: [3 Fill Sump Sensor(s). Model: n Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: n Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: [I Tank Overfill / High -Level Sensor. Model: n 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 Gas Dispenser ID: 314 Diesel ED Dispenser Containment Sensor(s). Model: Stand Alone 0 Dispenser Containment Sensor(s). Model: Stand Alone [I Shear Valve(s). 0 Shear Valvo(s� 0 Dispenser Containment Float(s) and Chain(s), n Dispenser Containment Float(s) and ChaWs). Dispenser ID: 6/6 Gas Dispenser iD: 7/8 Diesel 0 Dispenser Containment Sensor(s). Model: Stand Alone 0 Dispenser Containment Sensor(s). Model: Stand Alone 0 Shear Valve(s). 0 Shear Valve(s). 0 Dispenser Containment Float(s) and Chain(s). 0 Dispenser Containment Float(s) and Chain(s). Dispenser 10D: Dispenser IUD: El Dispenser Containment Sensor(s). Model: n Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). ❑ Shear Valve(s). 0 Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chani(s). *117 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. 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): Sy In -up Alarm history report 'm Technician Name Gavin Williams Signature: Certification No.. ICC: XX4341042455 License. No.: CYS'Ll: 856771 Testing Company Name: Henderson Maintenance Company Phone No.: (209) 467-7573 Testing Company Address: PO Box 31325 Stockton, CA 95213 Date of Testing/Servicing: 4/18/2013 Page 1 of 3