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0 0 HLUt:1VtL MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California N�V 0 6 2 015 Authority Cited.•Chapter 6 7,Health and Safety Code;Chapter 16,Division 3, Title 23, California Code ofRegu ations This form must be used to document testing and servicing of mmdtoting equipment. A separate certification or E%=HENW ��"rq� monitoring Wtern control panel by the technician who performs the work. A copy of this form must be provided to the tank The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. s� " 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: 10/23/2014 B. Inventory of Equipment Tested/Certified Cheek the appropriate boxes to indicate specific equipment Inspectediserviced. Tank ID.- JET FUEL Tank ID: In-Tank Gauging Probe. Model: ❑in Tank Gauging Probe. Model: ®Armular Space or Vault Sensor. Model: VR 7943904M ®Annular Space or Vault Sensor. Model: ®Piping Surra►/Trench Sensor(s). Model: VR 794380.208 ❑Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Una Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Electronic Lane 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). ❑Other(specify equipment type and model in Section E on Page 21 Tank ID: OTHER-TRANSITION SUMP Tank ID: ❑in-Tank Gauging Probe, Model: ❑In-Tank Gauging Probe. Model: ❑Annular Space or Vault Sensor. Model: ❑Annular Space or Vault Sensor. Model: ®Piping Sump/Trench Sensor(s). Model: VR 794380-208 ❑Piping Sump/Trench Sensor(s). Model: ❑Fill Sump Sensor(,). Model: ❑Fill Sump Sensor(s). Model: ❑Mechanical Lick Leak Detector. Model: ❑Mechanical Line Lak Detector. Model: ❑Electronic Lire Leak Detector. Model: ❑Electronic tine Leak Detector. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑Otho(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(s). Model: ❑Dispenser Containment Se nsot(s). Model: ❑Shear Valve(s). ❑Shear Valve(s). ❑Disperser Containment Float(s)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 Chsin(s). Dispenser ID: Dispenser ID: ❑Disperser Containment Sensor(s). Model: ❑Dispenser Containment Sensot(s). Model: ❑Shear Valve(s). ❑Shear Volve(s). ❑Disperser Containment Float(s)and Chain(s). ❑Disperser 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 equi went. For any equipment capable of generating such reports,I have also attached a copy of the report;(check all that apply): [5 System set-tt /A,larm history report Technician Name(print}: Joe Barthodi Signature: +✓ Certification No.: B36852 License.No.: 6600 6-A C-10HAZ Testing Company Name: Elite IV Contractors Phone No.:(209) 461.6337 Testing Company Address: 2535 WIGWAM DR STOCKTON CA 95205 Date of Testing/Servicing: 10/23/2014 Page 1 of 3 Rev(2/08)