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MONITitING SYSTEM CERTIFIC&TION e By All Jurisdictions Within the State of Ca/ifomi Authority Cited: Chapter 6.7, He 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. 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 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 Site Address: 3633 DUCK CREEK DRIVE Contact Phone No: 943-3213 Facility Contact Person: MARK ARMSTRONG Make/Model of Monitoring System:TLS-350 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced Date of Testing/Service: 02/24/2006 Work Order Number: 2241139 CA Zip: 95215 Tank ID: 1 -DSL 12K Tank ID: 2 -DSL 6K %t In -Tank Gauging Probe. Model: MAG X In -Tank Gauging Probe. Model: MAG 51;1 Annular Space or Vault Sensor. Model: 420 Annular Space or Vault Sensor. Model: 420 71Piping Sump/trench Sensor(s). Model: 208 © Piping Sump/rrench Sensor(s). Model: 208 71 Fill Sump Sensor(s). Model: 208 ® Fill Sump Sensor(a). Model: 208 Mechanical Line Leak Detector. Model: LD2000 2LD2000 Mechanical Line Leak Detector, Model: Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: Tank OverflllHigh-Level Sensor. Model: Other (specify equipment type and model in Section E on page 2). 11 Other (specify equipment type and model in Section E on page 2). Tank ID: - Tank ID: - X1 In -Tank Gauging Probe. Model: MAG In -Tank Gauging Probe. Model: MAG X Annular Space or. Vault Sensor. Model: 420 71 Annular Space or Vault Sensor. Model: 420 xj Piping Sump/Trench Sensoria). Model: 208 Piping Sump/Trench Sensor(s). Model: 208 X Fill Sump Sensor(s). Model: 208 71Fill Sump Sensor(s). Model: 208 Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfll/High-Level Sensor. Model: Tank Overfill/High-Level Sensor. Model: X Other (specify equipment type and model in Section E on page 2). Othereci s equipment type and model in Section E on page 2). (p fy Dispenser 1/2 Dispenser ID: X❑ Dispenser Containment Sensor(s) Mcdel:208 X Dispenser Containment Sensor(s) Model:208 QX Shear Velvets). —X]Shear Valves) Dispenser Containment Float(s) and Cham(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: 2 SLV Dispenser ID: 3/4 X❑ Dispenser Containment Sensors) Model: 208 Dispenser Containment Sensor(s). Model: 208 71 Shear Valve(s). 71 Shear Velvets). Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: 3 SLV Dispenser ID: 0 Dispenser Containment Sensors) Model: 208 ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). ElDispenser 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): MX System set-up X❑ Alarm history report Technician Name (print): DOUGLAS HARTY Certification No.: Signature: _ License. No.: Testing Company Name:Tanknology Phone No.: (800) 800-4633 Site Address: 8900 Shoal Creek, Bldg. 200 Austin, TX 78757 Date of Testing/Servicing: 02/24/2006 Monitoring System Certification Page 1 of 3 Based on CA form dated 03/01