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Sep. 6. 2012 11:04AM RUMEX CONSTRUCTION No -5773 P. 2 MONPORING SYSTEM CIERTIFIATION For Use By All Jurisdictions Wfthin the State of California Authority Cited. Chapter 6, 7, Health and Safety Code; Chapter 16, Division 3, 71ile 23, Calfbrnla Code ofRegulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitoring system -control -gate] 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: STOCKTON CHP Bldg. No,: Site Address: - 3330 N AD ART RD City: STOCKTON — Zip: 95215 Facility Contact Person: JIM Contact Phone No.: (209) 943-8666 Make/Model of Monitoring System: TLS 360 Date of Testing/Servicing: 3/3012012 13. Inventory of Equipment Tested/Certified kAeM tA* appropriate boxes to ingicate speeme eguigmeat impeaed/servited: Tank ID; 87 RE PAIRS Tank ED; 0 In -Tank Gauging Probe. Model:- VR 0 Tn-T&* Gauging Probe. Model: 0 Annular Space or Vault Senor. Model., VR 420 nAnaular Space or Vault Sensor. Model: 9 Piping Sump / Trench SonsoT(s). Model., VR 208 [--) Piping Sump I Trench Semr(s). Model! ID Fin Sump Senot(s). Model: VR 208 Cj Pill Sump smsor(s), Model: 21 Mechanical Line Leak Detector. Model: FF PETRO 0 Mechanical Line Leak Detector. Model; n Electronic Line Leak Detector. Model: NA [:] Electronic Line Leak Detector. Model: ED Tank Overfill / High -Level Sensor. Model: FLAPPER 0 Tank Overfill / High -Level Senor. Model: 0 Other (specify equipment type and model in Section E on Page 2). 0 Other (specify equipment type and model in Section R on Page 2). Tank ED: Tank ID- ❑ X i -Tank Gauging Probe. Model; El In-Twa Gauging Probe. Model; ❑ Annular Space or Vault Sensor. Model; n Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Senor(a)- Model: 0 Piping Sump / Trench Sensor s), Model; nFill Sump Sensor(s). Model: n Fill Sump Senwr(g). Model: ❑ Mechanical Line Leak Detector. Model: n Mechanical Line Leak Detector. Model: n Electronic Line Leak Detector. Model: 0 Electronic, Line Leak Detector. Model: n Tank Overfill / High -Level Sensor. Model: nTok overfli / iiigh-Levei Senor. Model' ❑ Other (specify equipment type and model in Section E on Page 2). [1 Other (specify equipment type and model in Section E on Page 2). Dispenser ID: _112 Dispenser ID: 2) Dispenser Containment Sensor(s). Model: VR 208 E] Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). [I Shear Valve(s)- 0 Dispenser Containment Plost(s) and Chain(s), ElDispenser Containment Float(s) and Chain($). Dispenser 11): Dispenser ED; 0 Dispenser Containment Sonsor(s). Model- n Dispenser Containment Setwqs). Model., 5 Shear vaive(s), D Shear Valve(s), 0 Dispenser Containment Float(&) and Chain(s). 0 Dupenser Containment Float(g) and Chain(s). Dispenser ID: Dispenser ID: [:jDispenser Containment S=aar(s). Model: 0 Dispenser Containment Sensor(s). MoM; rl Shear Valve(s). El Shear VaIve(p). 0 Dispenser Contairuncnt Floats) and Cbain(s), ❑ Dispenser Containment Float(s) and Chain(s). *If the facility contains more tanks or dizensers. ooDV this form. Include information for every tank and disnenser at the facility - C. Certififttion -I certify that the equipment identified in this document was inspecWlserviced in accordance with the manufacturers' guidelines. Attached to this Certification is Information (e g. manufacturers' checklists) necessary to verify that this information 19 correct and & 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; (check all that apply): Z System set-up Alarm historport Technician Name (print): EIVINDBYE Signature: Certification No.: UT -8159613 License. No.: 872234 Testing Company Name: Rumex Construction Corp Phone No.: (559),271-3300 Testing Company Address: 4.878 N. Bendel Ave. Fresno, CA 93722 Date of Testing/Servicing: Page I of 3 Rev (2/08)