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MQNIORING SYSTEM CERTIF ATION For Use By All JuriSdictions Within the State of Califo Authority Cited. Chapter £.7, Health and Safety Code; Chapter 15, Division 3 Title 23, CeGfornia Coda of Regulations d servicing of monitoring equipment, If more than one monitoring system central panel is installed at the facility, a separate This fnnn must be used Sc dactrment testing an cern tion or, re must b re ar d fore ch mo itorin 5 Se of this folrm to the Iacai agency regulating g UST syr emskv�ithin�30 days) of taSt d tet. be provided to the tank system owner/operator. The ownerloperator must submit a copy A, General Information City; STOCKTON CA Zip: 95215 _ Fac(tity Name: RYDER 10718 Contact Phone Na: 943-3213 Site Addrass_ 3633 DUCK CREEK DR, R STAGECOACH RD Dake of Testing/Service', OFF HWY 99 R MARIPOSA RD Facility Contact Person: MARK ARMSTRONG Work Order Number: 2234627 Make/Madel of Monitoring System:'/RTLS350 B. Inventory of Equlpment Tested leertified Check the appropriate boxes to indicate specific egtlipment Inspectedlserviced Tank 10: 1 X l In -Yank Gauging Probe, Modei: MAG Annular Space or Vault Sensor. Model: u Piping Sumprrrench Sensor(s). Model: 205 Piping Sump/Trench Sensor(s). Fill Sump Sensor(s). Model: 298 Mechanical Line Leak Detector, Model: LD2000 Model: Electronic Line Leak Detector. Model: Model: Tank OverfilllMlgh-Level Sensor, Model; VEEDER-ROOT Other (specify equipment type and model in Section E an page 2). In -Tank Gauging Probe. Madel_ MAG Annular Space OF Vault Sensor. Model: 420 Piping Sump/Trench Sensor(s). Model: 205 Fill Sump Sen$ar(s). Madel' 208 Mechanical Line Leak Detector. Model: LD2000 Madel: Electronic Line Leak Detector. Model: Madel; Tank OverfifVHlgh-Level Sensor. Model; VEEDSR-ROOT Other (specify equipment type and model in Section I on page 2) Dispenser Containment Sensors) Model: 208 Shear Vaive(s). Dispenser Containment Float($) and Chain(s). 5enserlD_ 213 X] Dispenser Containment sensor(s) Sneer Valve(s). Dispenser Containment Roat(s) and Dispenser ID: 3 Pq Dispenser Containment Sensor(s) 7 Shear VSIve(s). Model' Tank 1D: 2 In -Tank Gauging Probe Annular Space or Vault Sensor. Piping SumpfTrench Sensor(s), Fill Sump Sensor(s). Mechanical Line Leak Detector. Eleetronic Line Leak Detector. Tank Cverfilt/High-Level Sensor Other (speclfy equipment type ai DSspenser Containment Sensor(: Shear ValveW Dispenser Containment Floats) Dispenser Containment Sensors; Shear Valve(s). Dispenser Containment Roat(s) ai Model: MAG Model; 420 Model; 208 Modal: 208 Dispenser ID: Model: 208 Dispenser Containment Sensor(s). Shear Valve(s). , Dispenser Oontainment Floats) and Chain(s), Dispenser Containment Float(S) an if the facility contalns more tanks or dispensers, Dopy this farm. Include information for every tank and dispens c. certification I certify that the equipment identified in this document was inspectedlserviced in accordance with the manufacturers` guidelines. Attached to this cerlificabon is Wormation (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, 1 have also attaGned Alarm history report a copy of the (Check all that apply): 0 System set-up I^! RAYMOND SIMMS Signature: Technician Name (print): License. No.: Certification No.: 005-05-0252 Phone No.- (e00) 800 4633 -resting Company Name:Tanknolog Site Address; 8501 N- MoPao Expressway. suite 400> Austin, T 778759 Date of TesurigiServieing; 03i28120fl5 Rn.sari an CA form dated 0310 1l 'd, 99N'°N..n4;.._ BtiENM-60Z 'dSNV6l dlaAd iN E:6 ]ON '9 'M In -Tank Cauging Probe. Model; � G Annular Space or Vault Sensor, Model: 420 piping SumplT•rench Sensor(s), Model: 295 Fill Sump Sensor(s). Model: 298 Mechanical Line Leak Detector. LD2000 Madel: Electronic Line beak Detector. Madel; Tank overfilllHigh-Level Senor. Model: VEEDER-ROOT Omer (specify equipment type and model in Section E on page 2). In -Tank Gauging Probe Annular Space or Vault Sensor. Piping SumpfTrench Sensor(s), Fill Sump Sensor(s). Mechanical Line Leak Detector. Eleetronic Line Leak Detector. Tank Cverfilt/High-Level Sensor Other (speclfy equipment type ai DSspenser Containment Sensor(: Shear ValveW Dispenser Containment Floats) Dispenser Containment Sensors; Shear Valve(s). Dispenser Containment Roat(s) ai Model: MAG Model; 420 Model; 208 Modal: 208 Dispenser ID: Model: 208 Dispenser Containment Sensor(s). Shear Valve(s). , Dispenser Oontainment Floats) and Chain(s), Dispenser Containment Float(S) an if the facility contalns more tanks or dispensers, Dopy this farm. Include information for every tank and dispens c. certification I certify that the equipment identified in this document was inspectedlserviced in accordance with the manufacturers` guidelines. Attached to this cerlificabon is Wormation (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, 1 have also attaGned Alarm history report a copy of the (Check all that apply): 0 System set-up I^! RAYMOND SIMMS Signature: Technician Name (print): License. No.: Certification No.: 005-05-0252 Phone No.- (e00) 800 4633 -resting Company Name:Tanknolog Site Address; 8501 N- MoPao Expressway. suite 400> Austin, T 778759 Date of TesurigiServieing; 03i28120fl5 Rn.sari an CA form dated 0310 1l 'd, 99N'°N..n4;.._ BtiENM-60Z 'dSNV6l dlaAd iN E:6 ]ON '9 'M