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Jan.21. 2011 2:08PM RUMEX CONSTRUCTION No -3858 P. 2/6 . .1 MONARING SYSTEM CERTIFIRLTION 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, California Code ofIL-gulations This form mw be used to document testing and servicing of monitoring equipment. A separate certification or report must ared 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: Stockton CHP Bldg, No.: Site Address: 3330 N. Ad Art Rd City. Stockton Zip: 95215 Facility Contact Person: Jim Murray Contact Phone No.: 209) 943-8666 Make/Modelof Monitoring System: VI& 7-,�y aro Date of Testing/Servicing: 11101a B. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indieste !gftific e9uil?mentGas gSS2serviced: Tank ID: 87 Tank ED; 0 In -Tank Gauging Probe. Model; Veeder Root 0 In -Tank Gauging Probe. Model, • Annular Space or Vault Sensor, Model; Wader Root 420 El Annular Space or Vault Sensor. Model: • Piping Sump / Trorzh Samr(s), Model: Vender Root 208 0 Piping Sump / Trench Sensor(s). Model., • Fill Sump Sonsoi(s), Model: Veader Root 208 0 Fill Sump Sensor(s). Model: [D Mechanical Line Leak Detector. Model: FE Petro 0 Mechanical Line Leak Octoctor. Model; 0 Electronic Line Leak Detedor. Model: 0 Electronic Lino Leak Detector, Model; * Tank Overfill / high-level Sensor. Model: FW1222r 0 Tank Overfill / High -Level Sensor, Model: * Other (specify equipment type and model in Section E on Page 2). El Other (specify equipment type and model in Section E on Page 2). Tank ED: Tank ID., C3 In -Tank Gauging Probe. Model., [I In -Tank Gauging Probe. Model: n Annular Space or Vault Sensor. Model., 0 Annular Space or Vault Sensor. Model: 0 Piping Sump / Trench Sensor(s). Model: 0 Piping Sump / Trench Sensor(s). Model: 0 Fill Sump SensoKs). Model; 0 Fill Sump Sensor(s). Model: 0 Mechanical Lim Leak Detector. Model, 0 Mechanical Line Leak Detector. Model: 0 Eketromo Line Leak Detector. Modd, El Electronic Line Leak Detector. Model: C1 Tank Overfill / ffigh-Level Sensor. Model: [I Tank Overfill / High -Level Sensor. Model! [I Other (specify equipment type and model m SoctionE on Pago 2). ❑ Other (specify equipment W and model in Section E on Page 2). Dispenser ED: 112 Dispenser 11): 0 Dispenser Containment Sensoi(g). Model: Wader Root 208 0 Dispenser Containment Scasor(s). Model; 0 Shear Valve(s), [I shear vaive(s), C1 Dispenser Containment Floats) and Chain(s). ❑ Dispenser Co Float(s) and Chain(s). Dispenser ID: Dispenser ID: E) Dispenser Containment Sensor(s). Model: El Dispenser Containment Sensor(s), Model: El Shear Valvc(t). [I Shear Valve(s), C3 Dispenser Containment Float(s) and Chain(s). 0 Dispenser Contaimment Float(&) and Chain(s). Dispenser ID: Dispenser ID: [) Dispenser Containment Sensor(s). Model: [3 Dispenser Conzaiw= Sensor(s). Model. n Shear Valve(s). El Shear Valve(s), 0 Dispenser Containment Float(s) and Cham(s). [] Dispenser Containment Float(a) and Cha*s). *If the facility contains more tanks or dispensers, copy this form. Inelude 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 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 ail Mat apply): System set-up El Alarm history report .1 Technician Name (print): Jesus Garcla sigziarm- . ..... Certification No.: 8061091 -UT License. .872234 Testing Company Name: Rumex Construction Corp Phone No.: (569) 271-3300 Testing Company Address: 4670 N. Bendel Ave. Fresno, CA 93722 Date of Testing/Servicing: 1110/2011 Page 1 of 3 Rev (2/08)