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L • 17 Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at-,boe:L/WWW.wraterboar-ds.ca.gov.) 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 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 regulating UST systems within 30 days of test date. A. General Information Facility Name: Bank Of Stockton Bldg.No.: Site Address:1941 E Lockheed City:Stockton Zip:95215 Facility Contact Person:Norman White Contact Phone No.:_209 483-0257 Make/Model of Monitoring System:TLS 350 Date of Testing/Servicing:9/25/2017 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicate specific uipment inspected/serviced: Tank ID:Jet Fuel Tank ID: C i In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: U, Annular Space or Vault Sensor. Model: X Piping Sump/Trench Sensor(s). Model:409 0 Piping Sump/Trench Sensor(s). Model: X Fill Sump Sensor(s). Model:209 [i Fill Sump Sensor(s). Model: i i Mechanical Line Leak Detector. Model n Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: t.] Electronic Line Leak Detector. Model: I..i Tank Overfill/High-Level Sensor. Model r Tank Overfill/High-Level Sensor. Model: I i Others i e ui neon t e and model in Section E on Page 2). C Other(specify nuipment!ype and model in Section E on Page 2). TanklD: TanklD: U In-Tank Gauging Probe. Model: [_! In-Tank Gauging Probe. Model: ri Annular Space or Vault Sensor. Model: L Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: [:! Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Madel: L Fill Sump Sensor(s). Model: L Mechanical Line Leak Detector. Model: r. Mechanical Line Leak Detector. Madel: n Electronic Line Leak Detector. Model: L Electronic Line Leak Detector. Model: L Tank Overfill/High-Level Sensor. Model ❑ Tank Overfill i High-Level Sensor. Model: n Others i e uI ment tyEe and model in Section E on Pa 2). L Other(specify eguipment type and model in Section E on Page 2). Dispenser ID: Dispenser ID: Li Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: () Shear Valve(s).(OPW) a Shear Valve(s). n Dispenser Containment Float(s)and Chains. _p_Dispenser Containment Floats and Chain(s). Dispenser ID: Dispenser ID: F� Dispenser Containment Sensogs). Model: 1-1 Dispenser Containment Sensor(s). Model: () Shear Valve(s). (OPW) rl Shear Valve(s). R Dispenser Containment Floats and Chain(s). n Disp2nser Containment Floats and Chain(s). Dispenser lD: Dispenser ID: u Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: O Shear Valve(s). (DPW) U Shear Valve(s). r', Dispenser Containment Float(sj and Chains U Dis nser 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 equipmeW For any equlpm t capable of generating such reports,I have also attached a copy of the report;(check all that apply): FI System up ❑ rm hi report;' Technician Name(print):Joe Bartholdi Signature: Certification No.:836852 Lic .No.:1001331 A-HAZ Testing Company Name:ELITE IV CONTRACTORS Phone No.:L209_)_461-6337 Testing Company Address:2535 Wigwam Dr Stockton Ca 95205 Date of Testing/Servicing:_9/25/2017 Monitoring System Certification Page 1 of 4 12107 1 2/21/07