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MONITdbRING SYSTEM CETIFI TION For se By All Jurisdictions Within the State of Calif is 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 re monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system owner/opera The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. JUN 0 6 2011 A. General Information Facility Name: City of Stockton - CORP YARD ( SR0062470 ) Site Address: 1465 S Lincoln St City: Stockton, CA Facility Contact Person: Teri Williams Make/Model of Monitoring System: Veeder-Root TLS -350 PLUS B. Inventory of Equipment Tested/Certified Check the annronriate boxes to indicate specific equipment inspected/serviced: Contact Phone No.: (209 Bl EWRONMENTAL HEALTpf Zip: 95206 1 937-7416 Date of Testing/Servicing: 6/2/2011 D: T-1 (Diesel) Tank iD: T-2 (Regular 87) In Gauging Probe. FZAnnular Model: 107/570310 ® In -Tank Gauging Probe. Model: 1071570307 Space or Vault Sensor. Model: 303 / SER 1112 ® Annular Space or Vault Sensor. Model: 303 / SER 1113 ng Sump / Trench Sensor(s). Model: 208 / SER 873822 ® Piping Sump / Trench Sensor(s). Model: 208 / SER 877747 ❑ 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: ❑ 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 (specify equipment type and model in Section E on Page 2). Tank ID: N/A Tank ID: N/A ❑ 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: ❑ 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 (specify equipment type and model in Section E on Page 2). Dispenser ID: N/A Dispenser ID: NIA ❑ 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: N/A Dispenser ID: N/A ❑ 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: N/A Dispenser ID: N/A ❑ 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). *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 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): ® System set-up ® Alarm history report Technician Name (print): Carl Wayne Henderson Signature:_-�— Certification No.: ICC: 5252923 / VR: A25001 License. No.: CSLB: 856771 Testing Company Name: Henderson Maintenance Company - HMC Phone No.: (209) 467-7573 Testing Company Address: PO Box 31325 - Stockton, CA 95213 Date of Testing/Servicing: 6/2/2011 Page 1 of 3 Rev (2/08)