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d i°T}]/ krm2lo ]/ SYSTEM CERTIFICATION seBy All Jurisdictions Within the State of Califom Authority Cited:Chapter 6.7, #ONITORING and Safety Code;Chapter 16, Division 3 Title 23, dlifornia Code of Regulations This form must be used to document testing and servicing of monitoring equipment, If more than one monitoring system control panel is installed at the facility,a separate certification or report must be prepared for each monitoring sy§tem 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 Facility Name: RYDER 1071A City: STOCKTON CA Zip: 95215 Site Address: 3633 DUCK CREEK DR. @ STAGECOACH RD Contact Phone No:943-3213 OFF HWY 99 @ MARIPOSA RD Facility Contact Person: MARK ARMSTRONG Date of Testing/Service: 10!2412002 Make/Model of Monitoring System: VR TLS-3548 Work Order Number: 2224169 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced Tank ID: DSL MAIN Tank ID: DSL AUX X In-Tank Gauging Probe. Model: 847380-109 X In-Tank Gauging Probe. Model: 847380-107 X Annular Space or Vault Sensor. Model: 794390-420 X1 Annular Space or Vault Sensor. Model: 794390-420 X Piping Sump/Trench Sensor(s). Model: 794380-208 V1Aj Piping Sumpfrrench Sensor(s). Model 794380-208 Fill Sump Sensor(s). Model: Fill Sump Sensor(s), Model: Mechanical Line Leak Detector. Model: DLD Mechanical Line teak Detector. Model: FX1 DV Eiectronic Line Leak Detector. Model: Electronic'Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: 61 SO — X Tank Overfill/High-Level Sensor. Model: 61 SO Other(specify equipment type and model in Section E on page 2). Other(specify equipment type and model in Section E on page 2). Tank ID: NEW UIL Tank ID: X In-Tank Gauging Probe. Model: 847380-107 ZIIn-Tank Gauging Probe. Model: 847380-107 X Annular Space or Vault Sensor. Model: 794390-420 Annular Space or Vault Sensor. Model: X Piping Sump/Trench Sensor(s). Model: 794380-208 Piping Sump/Trench Sensor(s). Model: 794380-208 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: Electronic Line Leak Detector. Model: X Tank OverfiIIlHigh-Level Sensor. Model: 61SrJ 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). ispenser : 112 Dispenser ID: 3S &45 ❑Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s) Model: X❑Shear Valve(s). X Shear Valve(s) ❑Dispenser Containment Floats)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: 1S &2S Dispenser ID: ❑ Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s). Model: L^J Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: 314 DispenserlD: ❑ 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 Float(s)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 Site Plan showing the layout of monitoring equipment.For any equipment capable of generating such reports,I have also attached a copy of the(Check all that apply): System set-up report; FTI Alarm history report PRINTED NAME:MICHAEL T LEVESQUE SIGNATURE: COMPANY: Tanknology PHONE NO: (800)800-463.3 page 1 of 3 Based on CA form dated 03/01