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I MONI NG SYSTEM CERTIFI TION For Use By All Jurisdictions Within the State of California 2®® Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California' ulations i" 1 r HE4LTH This form must be used to document testing and servicing of monitoring equipment.A separate certification o ared for each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to t e 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: Bank of Stockton Bldg.No.: Hanger 3 Site Address: 1941 Lockheed Court City: Stockton Zip 95206 Facility Contact Person: Norm White Contact Phone No.: 209.483.0257 Make/Model of Monitoring System: Veeder-Root TLS-350 Date of Testing/Servicing: November 22,2006 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates ecific a ui ment inspected/serviced: Tank ID: #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: (x)Piping Sump/Trench Sensor(s). Model:0794380.208 ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model:S/N:618696 ❑ 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(specft a ui ment t e and model in Section E on Pae 2). 1 ❑ Other(specify equipment type and model in Section E on Page 2). Trans Sump Tank ID: ( )In-Tank Gauging Probe. Model:S/N:585394 ❑ In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model:409 ❑ Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model:0794380.208 ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model:S/N:602621 ❑ 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 equipment type and model in Section E on Page 2). 1 ❑ Other(specify 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 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). ❑ 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 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 ( )Alarm history report Technician Name(print): Eric Molgaard Signature.: Eric Morgaard Certification No.: VR AZ7995 License No.: 309105 Testing Company Name: STOCKTON SERVICE STATION EQUIPMENT CO.INC. Phone No 209-464-8333 Site Address: 1941 Lockheed Court Date of Testing/Servicing: November 22,2006 Page i of 3 03/01 Monitoring System Certification