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A. Appendix Vl (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at hftp://www.waterbogld§.ca.qov.) MONITORING SYSTEM CERTIFICATION` x " 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. General Information Facility Name: CHP Old Stockton Site Address: 3330 N. Ad Art Rd Facility Contact Person: .lames Murray Make/Model of Monitoring System: TLS 350 Bldg. No.: — city: Stockton, CA zip: 95215 B. Inventory of Equipment Tested/Certified Check the annronriate boxes to indicate specific equipment inspected/serviced: Contact Phone No.: 209-943-8666 Date of Testing/Servicing: 6/28/2017 Tank ID: T1 87 Tank ID: ,: in -Tank Gauging Probe. Model: MAG -1 ❑ In -Tank Gauging Probe. Model: ri Annular Space or Vault Sensor. Model: 420 - Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: 208 ❑ Piping Sump / Trench Sensor(s). Model: Fill Sump Sensor(s). Model: 208 =' Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: Ri Electronic Line Leak Detector. Model: PLLD ❑ Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: Tank Overfill / High -Level Sensor. Model: Other s eci a ui ment type and model in Section E on Page 2). ❑ Other �specijy equipment!ype and model in Section E on Pa2e 2). Tank ID: 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: Piping Sump / Trench Sensor(s). Model: Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model CI Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: Tank Overfill / High -Level Sensor. Model: Other (speciU eguiEment!XEe and model in Section E on Pa e 2 . ❑ Other (specily a ui ment t e and model in Section Dispenser ID: 1/2 Dispenser ID: V Dispenser Containment Sensor(s). Model VR 208 ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). ❑ Dispenser Containment Floats and Chains . Dispenser Containment Floats 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 Floats and Chains . Dispenser Containment Floats and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). 7 Shear Valve(s). ❑ Dis enser Containment Floats and Chains . ❑ Dispenser Containment Float�sj and Chains . 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 equipment For any equipment capable of generating such reports, I have also attached a copy of the report; (check all that apply): System set-up ❑ Alarm history report Technician Name (print): Hamzah Abdallait Certification No.: 848296 Testing Company Name: EPIC Environmental Compliance Systems Inc. Testing Company Address: 39120 Argonaut Way # 643, Fremont, CA 94538 Signature: License. No.: 9§576653 Phone No.: 888 -700 -EPIC Date of Testing/Servicing: 6/28/2017 Monitoring System Certification Page 1 of 4 12/07 1 2/21/07