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MONITAWNG SYSTEM CERTIF TION For se By All Jurisdictions Within the State of Cali ,, 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 certificatij6"-s�' I� 'ilred for 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 form to the local agency regulatingJfiT2yer 'thin 30 days of test date. `� A. General Information Facility Name: BANK of STOCKTON, METRO AIRPORT Site Address: 4800 S. AIRPORT WAY Facility Contact Person: Norm White Make/Model of Monitoring System: Pollulert Model FD103 Serial Number: N1031187047 B. Inventory of Equipment Tested/Certified Check t e appropriate boxes to indicatespecific equipment inspected/serviced: ENVIRONMENT HEALTH Bldg. No.: GATE 16, HANGEIPSRMIT/SERVICES City: STOCKTON Zip 95206 Contact Phone No.: (209) 483-0257 Date of Testing/Servicing: January 27, 2004 @ 9:30 a.m. Tank ID: JET FUEL TANK #1 Tank ID: 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: MD241RRA ❑ Fill Sump Sensor(s). Model: Serial: FMD241RRA ❑ 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 a and model in Section E on Pae 2). Tank ID: TankID: ❑ 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: ❑ Others eci equipment a and model in Section E on Pae 2). ❑ Others eci equipment a and model in Section E on Pae 2). Dispenser ID: Dispenser ID: ( )Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dis enser Containment Float(s) and Chain(s). ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Floats and Chain(s). ❑ Dispenser Containment Floats 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): MIKE JONES Signature: Mike Jones Certification No.: License. No.: 0019 Testing Company Name: Stockton Service Station Equipment Co., Inc. Phone No.:(209)464-8333 Site Address: 808 N. Union Street, Stockton, CA 95205 Date of Testing/Servicing_ January 27, 2004 1 of 3 03/01 Monitoring System Certification