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04/12/2012 12:42 (209) 465-4933 Wayne Henderson Page 115 Appendix VI ` MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California ry Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Co L 012 Regulations This form must be used to document testing and servicing of monitoring equipment A separate certification or report must be prepared for ° 'f Es •) i° 4, each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank syste#t} (.. ;`a i ownerloperator. The ownerloperator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General information Facility fJamA CITY OF STOCKTON -- CORP YARD Site Address: 1465 S. LINCOLN ST. Facility Contact Person: TERRY WILLIAMS Make/Model of Monitoring System: AUTO STIK .IR Bldg. No.: city: STOCKTON, CA zip: 45240 Contact Phone No,: ( } B. inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific eauipment inspectedlserviced: Date of Testing;Servicing: 311012011 Tank ID: 87 Tank Size= 10 K Tank ID: Tank Size: ® in -Tank Gauging Probe. Model MAG ❑ in -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: LS -30A. ❑ Annular Space or Vault Sensor. Model: ® Piping Sump / Trench Sensor(s). Model: LS -3 ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model. SUCTION ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill ! High -Level Sensor. Model: ❑ Tank Overfill J High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: DIE Tank Size: I0 K Tank 10: Tank Size: ® In -Tank Gauging Probe. Modes: MAG ❑ In -Tank Gauging Probe_ Model: ® Annular Space or Vault Sensor. Model- LS -30A ❑ Annular Space or Vault Sensor. Model: ® Piping Sump 1 Trench Sensor(s). Model: LS -3 ❑ Piping Sump i Trench Sensor(s). Model: ❑ Fill Sump Sensor(s')_ Model: ❑ Fill Sump Sensor(s). Model: [3 Mechanical Line Leak Detector. Model: SECTION [3 Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill ! High -Level Sensor. Model: ❑ Tank Overfill J High -Level Sensor. Model: ❑ 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 10: 1/2 Dispenser ID; 3!4 ® Dispenser Containment Sensor(s). Model: 13E.I-406 ® Dispenser Containment Sensor(s). Model: BE.I-406 ® ShearValve(s). ® ShearValve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5/6 Dispenser ID: 7/8 ® Dispenser Containment Sensor(s)_ Model: BEI -406 ® Dispenser Containment Sensor(s). Model: BEI -406 ® Shear Valve(s). ® Shear Valve(s)- [3 Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Floats) and Chain(s). Dispenser ID; Dispenser ID: ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(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 - 1 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 Pian 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 thal apply): ® System set-up ® Alarm history report Technician Name (print): ZANE NIMMO Signature: ""' Certification No.: A28446 License No: 04-1676 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 Testing Company Address: 416 2"° STREET GALT, CA 95632 Date of Testing/Servicing: .31101111 Monitoring System Certification Page 1 o€4 2/2l i07