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MONITORING SYSTEM CERTIFICATI RECEIVED ON For Use By All Jurisdictions Within the State of California Authority Cited:Chapter 6.7,Health and Safety Code,Chapter 16,Division 3, 27tle 23, California Code of ReAQoA 6 2 015 This form must be used to document testing and servicing of monitoring equipment.A Kparate certi8 TAL monitoring system control mW by the technician who performs the work. A copy of this form must be provided to the tan gggiAGh1T The owner/operator must submit a copy of this form to the local agency regulating[1ST systems within 30 days of test date. A. General Information Facility Name: BANK OF STOCKTON Bldg.No.: Hanger#3 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: 10/15/2013 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates eelf a equipment Ins serviced: Tank ID: JET FUEL Tank ID: ❑In-Tank Gauging Probe. Model: ❑in Tank Gauging Probe. Model: ®Annular Space or Vault Sensor. Model: VR 794390-409 ®Annular Space or Vault Sensor. Model: ®Piping Sump/Trench Sensor(s). Model: VR 794380-208 ❑Piping Sump/Trench Sen ser(s). Model: ❑Fill Sump Sensor(s), Model: ❑Fill Sump Sensor(s). Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ❑Electronic Lire Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Tank Overfill/High-Level Sensor, Model: ❑Tank Overfell/High-Level Sensor. Model: ❑Other(specify equiprneut type and model in Section E on Page 2). ❑Other(specify equipment type and model in Section E on Page 2). Tank ID: OTHER-TRANSITION SUMP Tank ID: ❑Ln-Tank Gauging Probe. Model: ❑In-'ihnk Gauging Probe. Madel: ❑Annular Space or Vault Sensor. Model: ❑Annular Space or Vault Sensor. Model: ®Piping Sump/Trench Sensor(s). Model: VR 794380-208 ❑Piping Sump/Trench Sensot(s). Model: ❑Fill Sump Sensof(s). Model: ❑Fill Sump Sensor(s). Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Lino Leak Detector. Model: ❑Electronic Lane Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Tank Overfill/High-Levo!Sensor. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑Other(specify equipment type and model in Section E on Page 2). ❑Other(specify equipment type and model in Section E on Page 2). Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensor(&). Model: ❑Dispenser Containment Sensor(s). Model: ❑Shear Valve(s). ❑Shur Valve(s). ❑Dispenser Containment Rugs)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). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Floats)and ChaKs). Dispenser ID: I 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 Flows)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. CertiffCatiOn - 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;(cheek all that apply): [�Syste ret- Al en history report Technician Name(print): Joe Barthodi Signature:— ./A, a Certification No.: 836852 License.No.: 076-A1S3C-I0HAZ Testing Company Name: Elite IV Contractors Phone No.:(209) 461-6337 Testing Company Address: 2535 WIGWAM DR STOCKTON CA 95205 Date of Testing/Servicing: 10/16/2013 Page 1 of 3 Rev(2/08)