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Feb -26. 2013 10:30AM RUMEX CONSTRUCTION No -8254 P. 9 t) NG SYSTEM CERTIN OTION For Use �" Alt Jurisdictions Within the State of Cal rnia Health Authority Cited., Chapter 6, 7, H and Safety Code; 4 Chapter 16, Division 3, 22e 023, California Code ofAegulations This form must be used to document testing and servicing of monitoring equipment. A �paraft certification or ret)ort mug be LreRWtLfor _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 IwAl agency regulating UST systems within 30 days of test date, A. General Information Facility Name: STOCKTON CHP Bldg. No.: Site Address: 3330 AD ART RD City: $TOCKTON - Zip: 95216 Facility Contact Person; JIM MURRAY Contact Phone No., (209) 943-8666 Make/Model of Monitoring System: TLS -360 Date of Testing/Servicing- 2122/2013 B. Inventory of Equipment Teste&Cerfified Cheek the souroortate boxes to Indicate softifie equipment ins serviced; Tank 10: 87 Tank ID: 0 In -Tank Gauging Probe. Modot; VR El In -Tank Gauging Probe. Model: 0 Annular Space or Vault Sensor, Model; VR 420 Annular Space or Vault Sensor. Model: Z Piping Sump / Trench Sensor(s). Model: Vill 208 ❑ Piping Sump / Trench Sensor(s). Model! 0 Fill Sump Sensor(g). Model: VR 208 ❑ Fill Sump Sensor(s). Model! 0 Mechanical Una Leak Detector. Model, FE PETRO Mechanical Line Leak Detector. Model! [3 Electronic Line Leak Detector. Model! NA ❑ Electronic Line Lea Detector. Model: Tank Overfill / High -Level Sensor, Model: FLAPPER r7l Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). [1 Other (specify equipment "c and model in Section E on Page 2). Tante ID; Tank III: El In -Tank Crauging. Probe. Model: [I In -Tank Gauging Probe, Model; 0 Annular Space or Vault Sensor. Model: [] Annular Space Or Vault Sensor, Model; [I Piping Sump I Trench Sensor(s), Model: E] Piping Sump I Trench Sensor(s). Model: [I Fill Sump Scrisor(s), Model; [3 fill Sump Senwr(s). Model: ❑ Mechanical Yinc Usk Detector, Model; [3 Mechanical Line Leak Detector. Model: ❑ Electronic Lino Leak Detector, Model: [3 Electronic Line Leak Detector. Model- ❑ Tank Overfill / High -Level Sensor. Model: [3 Tank Overfill / High -Level Sensor. Mode): ❑ Other (specify equipment type and model in Section R on Page 2). [3 Other (specify equipment type and model in Section E on Page 2). Dispenser ED: 1/2 Dispenser ID: Dispenser Containment Sensor(s). Model., VR 208 [1 Dispenser Containment Scrisor(s). Model: Shear Valve(&). D Shear Valvo(s). El Dispenser Containment Float(s) and Chain(s). [3 Dispenser Containment Float(s) and Chain(s). Dispenser ID; Dispenser ID: 0 Dispenser Containment Sensor(s). Model: [I Dispenser Containment Sensor(s). Model: [I Shear Valve(s). [I Shear Valve(s), -0 Dispenser Containment flom(s) and Chain(s), [3 Dispenser Containment Float(s) and Chain(s). Dispenser ID; Dispenser W: [I Dispenser Containment Sensor(s). Model: [I Dispenser Containment Sonsor(s), Model; 0 Shear valve(s). [] Shear Valve($), LD Dispenser Containment Float(s) and Chain(s). [3 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 doeument 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; (ekeek all that apply): System set-up 0 Alarm history rep)" Technician Nam (print): EIVIND BYE Signature: Certification No.: UT -8169613 License. No.: 872234 Testing Company Name: RUMEX CONSTRUCTION CORPORATION Phone No,: (669) 271-3300 Testing Company Address: 4670 N. BENDEL AVE FRESNO, CA 93722 Date, of Testing/Servicing: 2122/2013 Page I of 3 Rev (2/08)