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0 Appendflx N11 ^vlis (Copies of Monitoring Sy,tem Certification form and UST Monitoring Plot Plan available athtt ://w )� MONITORING SYSTEl CERTIFICATIONr� For Use By All Jurisdictions Within the State of California 0 ') �d09 Authority Cited. Chapter 6.7, health and Safety Code; Chopler 16, Division 3, Title 23, California Co 6ulations This form must be used to document testis and servicing of iiionitoring equipment. A separate certification or re o U �� f�� g g l i P P '� i monitoring system control by the technician who performs the work. A copy of this form must be provided to the tank ys INEF, 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 Site Address: 1465 S. Lincoln St. Facility Contact Person: Terri Williams Make/Model of Monitoring System: I- uto-Stile Jr. B. Inventory of Equipment Tcst-cd/Certified Check the appropriate boxes to indicate specific equipment inspected/scrNices Tank ID: #1 Unleaded El In -Tank Gauging Probe. M(,,dc1: 7100 EBW (x)Annular Space or Vault Sensor. M% -:)del: LS -30A (x)Piping Sump / Trench; Sensor(s). Model: LS -3A ❑ Fill Sump Sensor(s). Model: ( )Mechanical Line Leak Detector. Model: ❑ Electronic Line beak Detector. Model: _ ❑ Tank Overfill / l ligh-Level Sensor. Model• ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: #2 Diesel (x)In-Tank Gauging Probe. M -del: 7100 EBW ❑x Annular Space or Vault Sensor. Model: LS -30A ❑x Piping Sump /Trench Sensor(s). Model: LS -3A ❑ Fill Sump Sensor(s). Model: C3 Mechanical Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / Iligh-Level Sensor. Model: _ ❑ Other (spec iry equipment type and mode; in Section E on Page 2) Dispenser 1D: 1 and 2 (x)Dispenser Containment Sensor(s). Modcl: 406 Beaudreau Shear Valve(s). ( )Dispenser Containment Float(s) and Chain(s). _ Dispenser Ill. 3 and 4 ❑x Dispenser Containment Sensor(s). Mod, I: 406 Beaudreau Shear Valve(s). ❑ Disnenser Containment Float(s) and Chain(s). Dispenser ID: 5 and 6 x❑ Dispenser Containment Sensor(s). Model: 406 Beaudreau Shear Valve(s). ❑Dispenser Containment Float(s) and Cb,in(s). *If the facility contains more tanks or dispensers, copy this form Bldg. No.: Corporation Yard City: Stockton Zip 95206 Contact Phor.., No.: 209-937-7416 Date of Testing/Servicing: March 19, 2009 Tsink ID: DI rn- I'ank Gauging Probe. Model: U Annular Space or Vault Sensor. Model: C. Pining Sump/ Trench Sensor(s). Model: U 1 1 1 Sump Sensor(s). Model: ❑ Mt:hanical Line Leak Detector. Model: C] FI,_ :6onic Line Leak Detector. Model: U Tar'!; Overfill /I ligh-Level Sensor. Model: _ L7 C' her (specify equipment type and model in Section E on Page 2). 'fanh ID: ❑ In -Tank Gauging Probe. Model: C1 ;Vinular Space or Vault Sensor. Model: tiling Sump / Trench Sensor(s). Model: O fill Sump Sensor(s). Model: '%1cr.:hanieal Line Leak Detector. Model: L.1 I:icctronic Line beak Detector. Model: _ 1 "1' ::1< Overfill / ITigh-Level Sensor. Model: t` -;ci (specify equipment type and model in Section E on Page 2). I3isih ;rser ID: 7 and 8 (I D1, )enser Containment Sensor(s). `A .'111,1i-valve(s). �_d :)i,nt:nser Containment Float(s) and h 1< ser ID: ' _'._.,eraser Containment Sensor(s). Valve(s). I' s,miser Containment Float(s) and r .�; cnser Containment Sensor(s). Model: a Vatvc(s). unser Containment Float(s) and Chain(s). Model: 406 Beaudreau Model: Include n , Pr C:on for ever), tank and dispenser at the facility C. Certification - I certify that the equipment identified in this docanreni was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e.g. msr ,;,:r:=