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00 RECEIVED Appendix V1 OCT 2 8 2016 (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at hb://www.watet�oards.ca.gov.) MONITORING SYSTEM CERTIFICATION ENVIRONMENTAL HEALTH For Use By All Jurisdictions Within the State of California DEPARTMENT 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 LIST systems within 30 days of test date. A. General Information Facility Name: —Bank of Stockton Bldg.No.: 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_1_10_/ 2016 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to.,indicates pecific eguiement Ins ected/serviced: Tank ID:Jet Fuel Tank ID: Fj In-Tank Gauging Probe. Model: I_; In-Tank Gauging Probe. Model: j Annular Space or Vault Sensor. Model:V/R-409 0 Annular Space or Vault Sensor. Model: � Piping Sump/Trench Sensor(s)- Model:VIR-209 t, Piping Sump/Trench Sensor(s). Model: i-, Fill Sump Sensor(s). Model: FFill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: 7! 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: rOther�sEnci!y equieTent t and model in Section E on Page 2). Other(speci!y equ!Ment type and model in Section E Tank ID: Tank ID: In-Tank Gauging Probe. Model: u In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: i Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: Piping Sump I Trench Sensor(s). Model: j Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: L, Mechanical Line Leak Detector. Model: Li Mechanical Line Leak Detector. Model: I IJ Electronic Line Leak Detector. Model: is Electronic Line Leak Detector. Model: rL, Tank Overfill/High-Level Sensor, Model: "j Tank Overfill/High-Level Sensor. Model: [f' Other�specify!3uiRTent tXpe and model in Section E on Page 2). 3 Other js2!c!�equipment tg!and model In Section E on Page 2). Dispenser 10:TOKHEIM PREMIER C— Dispenser ID: Dispenser Containment Sensor(s). Model: F Dispenser Containment Sensor(s). Model: 13 Shear Valve(s).(OPW) L Shear Valve(s). f D 3 L, Dispenser Containment Float(s)and Chain(s). u Dispenser Containment Float(s)and Chaln(sj. Dispenser ID:PERMIER Dispenser ID: ur Dispenser Containment Sensor(s). Model: E Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). (OPW) Shear Valve(s). i Dispenser Containment Float(s)and Chaln(s). IF Disp2nser Containment Float(s)and Chain(s). 9 Dispenser ID:PREMIER 7Dispenser ID: Dispenser Containment Sensor(s). Model: 7, Dispenser Containment Senso�s). Model: [3 Shear Valve(s). (DPW) Shear Valve(s). 10 Dispenser Containment Float(s)and Chains �Dis nser Containment Float(s)and Chain(s). *If the facilitycontainsmore—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): D System set-up -i AlZisto ort Technician Name(print):JOE BARTHOLDI_ Signature: 10, Certification No.: Licen .No.:1001331 A-HAZ Testing Company Name:ELITE IV CONTRACTORS _ Phone No.:(_209–)_461-6337 Testing Company Address:2535 Wigwam Dr Stockton Ca_95205 Date of TesUng/Servicing:_10110/2016— Monitoring System Certification Page I of 4 12J07 1 2/21/07