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1 0 Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available athttp://www.swrb.ca.poy) MONITORING SYSTEM CERTIFICATION 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, California Code of Regulations - 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 syst ower/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. 'D i , i j1�� ! � �� 1/ED/ A. General Information Facility Name: City of Stockton Bldg. No.: Corporation Yard MAR1 4 2008 Site Address: 1465 S. Lincoln St. City: Stockton Zip 95206 Facility Contact Person: Phil Burnside Contact Phone No.: 209-937-7417 F-NVi ',aNr Y`N 'i HEAL1 H Make/Model of Monitoring System: Auto-Stik Jr. Date of Testing/Servicing: March 6, 2000FRt.f SERVICES B. Inventory of Equipment Tested/Certified Check the annronriate boxes to indicate specific eauinment inspected/serviced: Tank ID: #1 Unleaded Tank ID: Ll In -Tank Gauging Probe. Model: _ In -Tarek Gauging Probe. Model: 7100 (x)Annular Space or Vault Sensor. Model: LS -30A ❑ Annular Space or Vault Sensor. Model: ( )Piping Sump/ Trench Sensor(s). ❑ Fill Sump Sensor(s). Model: LS -3A Model: ❑ Piping Sump / Trench Sensor(s). ❑ Fill Sump Sensor(s). Model: 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. ❑ Other s eci equipment type and Model: model in Section Eon Pae 2). ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: #2 Diesel Tank ID: ❑ In -Tank Gauging Probe. Model: ( )In -Tank Gauging Probe. Model: 7100 Annular Space or Vault Sensor. Model: LS -30A ❑ Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). ❑ Fill Sump Sensor(s). Model: LS -3A Model: ❑ Piping Sump / Trench Sensor(s). ❑ Fill Sump Sensor(s). Model: 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 tye and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: 1 and 2 Dispenser ID: 7 and 8 () Dispenser Containment Sensor(s). Model: 404 Beaudreau ❑ Dispenser Containment Sensor(s). Model: 404 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: Dispenser Containment Sensor(s). Model: 404 Beaudreau ❑ 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: 5 and 6 Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: 404 Beaudreau ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Floats 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: .t[e ON -10 atd 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/Seryicing: March 6, 2008 Monitoring System Certification Page 1 of 4 12/07 1