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so yt• MOTORING SYSTEM CERTIFICATION • 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,Califomia Code of Regulations This form must he 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 system control panel by the technician who performs the work. A copy of this form must be provided to the tank system ownerloperator. The ownerloperator 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 DRIVE Contact Phone No:943-3213 Date of Testing/Service: 10131/2001 Facility Contact Person: JERRY DUDLEY MakelModel of Monitoring System: TLS350 Work Order Number: 2219144 B.Inventory of Equipment TestedlCertified Check the appropriate boxes to indicate specific equipment inspected/serviced Tank ID: DIE/MAIN Tank ID: DIE/RES X In-Tank Gauging Probe. Model MAO' 71 In-Tank Gauging Probe. Model: MAG X Annular Space or Vault Sensor. Model: 794390420 Annular Space or Vault Sensor. Model: 794390420 X Piping Sump/Trench Sensor(s). Model: 794380208 Piping Sump/Trench Sensor(s). Model: 794380208 Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: XLD Mechanical Line Leak Detector. Model: FXi Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overrill/High-Level Sensor. Model: Tank OvertilllHigh-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). Tank ID: Ta": X In-Tank Gauging Probe. Model: MAG In-Tank Gauging Prone. Model: MAG X Annular Space or Vault Sensor. Model: 794390420 Annular Space or Vault Sensor. Model: X Piping Sumpfl"reneh Sensor(s). Model: 794380208 Piping SumplTrench Sensor(s). Model: 794380208 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: Tank Overfill/High-Level Sensor. Model: Tank Overfill/Rgh-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 I D: 112 Dispenser ID: Dispenser Containment Sensor(s) Model:NONE Dispenser Containment Sensor(s) Model: Shear Valve(s). Shear Valve(s) ❑Dispenser Containment Float(s)and Cl Dispenser Containment Float(s)and Cl Dispenser ID: 314 Dispenser ID: ❑ Dispenser Containment Sensor(s) Model:NONE Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Cl Dispenser ID: 516 Dispenser ID: ❑ Dispenser Containment Sensor(s) Model NONE Dispenser Containment Sensor(s). Madel: ❑ Shear Valve(s). Shear Valve(s). ❑ Dispenser Containment Float(s)and Cl Dispenser 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 inspectediserviced in accordance with the manufacturersguidelines. 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; ❑X Alarm history report X❑ PRINTED NAME-DAVID MATHIE SIGNATURE: COMPANY: Tanknology PHONE NO: 800 800-4633 page 1 of 3 Based on CA form dated 03101