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Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at h%/-/www waterboards.ca-clov.) 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 Bldg.No.: Facility Name: _Bank of Stockton Site Address:1941 Lockheed Ct City: Stockton Zip:_95206 Facility Contact Person:Norman White Contact Phone No.:(209)_483-0257_ Make/Model of Monitoring System:Veeder-root TLS 350 Date of Testing/Servicing:_10_/_10 L 2016 B. Inventory of Equipment Tested/Certified Checkthea ro riate boxes to indicates ific equiRMent ins cted/serviced: Tank ID:Jet Fuel Tank ID: D In-Tank Gauging Probe. Model:V/R-115 ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model:V/R-409 ❑ Annular Space or Vault Sensor. Model: D Piping Sump/Trench Sensor(s). Model:V1R 208 ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model:N!A a Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model:N/A ❑ Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model:N/A a Electronic Line Leak Detector. Model: ❑ Tank Overfill 1 High-Level Sensor. Model:V1R u Tank Overfill/High-Level Sensor. Model: ❑ Others i ui ment to and model in Section E on Pae 2). u Others equipM22t a and model in Section E on EM 21. Tank ID:_Other Transition Sumps Tank ID: u In-Tank Gauging Probe. I: D In-Tank Gauging Probe. Model: u Annular S or Vault Sensor. Model: nAnnular Space or Vault Sensor. Model: U Piping Sump/Trench Sensor(s). Model:V/R 794380-208 ❑ Piping Sump/Trench Sensor(s). Model: U Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Li Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: L] Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: u Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Others a ui ment=and model in Section E on EM 21. u Other JSB=2quipMent and model in Section E on P 12). Dispenser ID:TOKHEIM PREMIER C Dispenser ID: u Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s).(OPW) ❑ Shear Valve(s). ❑ Di nser Containment Fbat s and Chains). D Di neer Containment Floa s and Chains. Dispenser ID:PERMIER Dispenser ID: D Dispenser Containment Sensor(s). Model: u Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). (OPW) u Shear Valve(s). D Dls nser Containment FLoft and Chains. u Dis neer Containment F sand Chains. Dispenser!D:PREMIER Dispenser ID: Li Dispenser Containment Sensor(s). Model: D Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). (DPW) ❑ Shear ser Containment Ea Dis nser Containment Float s and Chains ❑ 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 inspectedlservic ed 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 equ ent capable of generating such reports,!have also attached a copy of the report;(check all that apply): ❑System set-up 1i Alm .story report R Signature:na Technician Name(print):JOE BARTHOLDI Certification No.: License. .o.:1001331 A=H Testing Company Name:ELITE IV CONTRACTORS Phone No.:(_209j 461-6337 Testing Company Address:2535 Wigwam Or Stockton Ca_95205 Date of Testing/Servicing:_10/10/2016_ Monitoring System Certification Page 1 of 4RECNED 12107 NOV 16 2016 1 ENVIRONMENTAL HEALTH 2/21/07 DEPARTMENT