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• RWED�� ` Appendix VI 0 (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available athtt :/ ni" str4a 44 MONITORING SYSTEM CERTIFICATNAbNMENT HEALTH 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, Calif i�W ions 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 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: City of Stockton Bldg. No.: Corporation Yard Site Address: 1465 S. Lincoln St. City: Stockton Zip 95206 Facility Contact Person: Terri Williams Contact Phone No.: 209-937-7416 Make/Model of Monitoring System: Auto-Stik Jr. Date of Testing/Servicing: March 11, 2010 B. Inventory of Equipment Tested/Certified ♦.. {.......� 4n :...iinnfP e.ePniin Pnninm Pnf is CnPntP/I �CPL'VI1`Prl• v eeea. e..m ee, u l.Il cc. N L a I V e ea vvn e.o a.e..aa..., ... ........ ..... ........-. ..-. . _--__ Tank ID: #1 Unleaded Tank ID: ❑ In -Tank Gauging Probe. Model: _. El In -Tank Gauging Probe. Model: 7100 EBW F (x)Annular Space or Vault Sensor. Model: LS -30A ❑ Annular Space or Vault Sensor. Model: (x)Piping Sump / Trench Sensor(s). Model: LS -3A ❑ 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 e ui ment type and model in Section E on Page 2 . ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: #2 Diesel Tank ID: ❑ In -Tank Gauging Probe. Model: _ (x)In-Tank Gauging Probe. Model: 7100 EBW ® Annular Space or Vault Sensor. Model: LS -30A ❑ Annular Space or Vault Sensor. Model - 0 Piping Sump / Trench Sensor(s). Model: LS -3A ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: _ ❑ Fill Sump Sensor(s). odel:_❑ Model:.---- LIMechanical 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: ❑ 'rank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and Dispenser ID: 7 and 8 model in Section E on Page 2). Dispenser 1D: 1 and 2 (x)Dispenser Containment Sensor(s) Model: 406 Beaudreau 0 Dispenser Containment Sensor(s). Model: 406 Beaudreau Shear Valve(s). ❑ Shear Valve(s). ( ) Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 3 and 4 Dispenser ID: M Dispenser Containment Sensor(s). Model: 406 Beaudreau ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). ❑ Shear Valve(s). _T Denser Containment Float(s) and Chain(s). El Dispenser Containment Float(s) and Chain(s)_ Dispenser ID: 5 and 6 Dispenser ID: Fx1 Dispenser Containment Sensor(s). Model: 406 Beaudreau ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). I L1 Shur Valve(s). I� ❑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 ( x) Alarm history report (REPORT WAS GIVEN TO INSPECTOR ON SITE) Technician Name (print): Eric Molgaard Signature: �&I, oNdj.td Certification No.: ICC, BEAUDREAU, O.P.W. License No.: 309105 Testing Company Name: STOCKTON SERVICE STATION EQUIPMENT CO. INC. Phone No 209-464-8333 Testing Company Address: 808 N. Union Street, Stockton, CA 95205-4152 Date of Testing/Servicing: March 11, 2010 Monitoring System Certification Page I of 4 12/07