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i i t r V Appendix VI a cup% E (Copies of Monitoring System Certification form and Uw ST Monitoring Plot Plan available at http://ww .waterboards.ca.gov.) h a ''USX, j a,.- 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 JUN 2 2 2009 Regulations This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be prepared for SAN JOAOUIN COUNTY each monitoring system control panel 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 forth to the local agency regulating UST systems within 30 days of test date. ENVIRONMENTAL HEALTH DEPAWMENT A. General Information Facility STOCKTON UNIFIED SCHOOL DIST Bldg.No.: Nam. Site ress 1832 EL PINAL City: STOCKTON Zip: Add Facility Contact BUTCH Contact Phone No.: (209)933-7045 Person Make/Model of Monitoring System: INCON Date of Testing/Servicing: 5(29(2009 B. Inventory of Equipment Tested/Certified Check the approeriate boxes to indicatespecific equipment inspected/serviced: Tank ID: 67 OCT Tank ID: DSL ® In-Tank Gauging Probe. Model: MAG ®In-Tank Gauging Probe. Model: MAG ®Annular Space or Vault Sensor. Model: ILS ®Annular Space or Vault Sensor. Model: ILS ® Piping Sump/Trench Sensor(s). Model: ULS ® Piping Sump/Trench Sensor(s). Model: ULS ❑ Fill Sump Sensor(s). Model: ®FII Sump Sensor(s). Model: ULS ®Mechanical Line Leak Detector. Model: FXLD ®Mechanical Line Leak Detector. Model: FX1 ❑ 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: NA Tank ID: NA ❑ 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 I 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: 1-2 Dispenser ID: ® Dispenser Containment Sensor(s). Model: ULS Cl 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: 3-4 Dispenser ID: ® Dispenser Containment Sensor(s). Model: ULS ❑ 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: 5-6 Dispenser ID: ❑Dispenser Containment ® Dispenser Containment Sensor(s). Mode(:ULS 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,1 have also attached a copy of the report;(check all that apply): ®System set-up ®Alarm history report Technician Name(print): David A.Winkler Signature: Certification No.: 34975 License No: OTT 08.1739 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 STREET GALT CA 95632 Date of Testing/Servidng: Monitoring System Certification Page 1 of 4 2/21/07 V