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MONITORING SYSTEM CERTIFICATION d,W 7b s r Use By All Jurisdictions Within the State of Calif Authority Cited.Chapter MWalth and Safety Code:Chapter 16, Division 3 Title lWalifornia 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. I he owner operator must su mita copy oTIT is orm tot a local agency regulating UST systems within 30 days of test date. A.General Information Gity: STOCKTON CA Zip:35215 Facility Name: RYDER 1071A Site Address: 3633 DUCK CREEK DRIVE Contact Phone No:943-3213 Date of Testing/Service: 10/31/2001 Facility Contact Person: JERRY DUDLEY Make/Model of Monitoring System: TLS350 Work Order Number: 2219144 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced Tank ID: DIEIMAIN Tank ID: DIEIRES In-Tank Gauging Probe. Model: MAG In-Tank Gauging Probe. Model: MAG Annular Space or Vault Sensor. Model: 794390420 Annular Space or Vault Sensor. Model: 794390420 Piping SumpfTrench Sensor(s). Model: 794380208 X Piping Sump/Trench Sensor(s). Model: 794380208 Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector, Model: XLD K Mechanical Line Leak Detector. Model: FX1 19 Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank OverfilVHigh-Level Sensor. Model: Tank Overfill[High-Level Sensor. Model: Other(specify equipment type and model in Section E on page 2). Other(specify equipment type and model in Section E on page 2). an an 71In-Tank Gauging Probe. Model: MAG In-Tank Gauging Probe. Model: MAG Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: 7943802Ud Piping Sumpfrrench Sensor(s). Model: 794380208 Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: Tank Overfill/High-Level Sensor. Model: Other(specify equipment type and model in Section E on page 2). Other(specify equipment type and model in Section E on page 2). u1sperlser 11J. 112 lspenser ❑ Dispenser Containment Sensors) Model: NONE Dispenser Containment Sensor(s) Model: F] Shear Valve(s). ShearValve(s QDispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s), lspenserjUispenser . Dispenser Containment Sensor(s) Model:NONE D Dispenser Containment Sensor(s). Model: EShearValve(s). ShearValve(s). Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: 516 Dispenser ID: Dispenser Containment Sensor(s) Model: NONE Dispenser Containment Sensor(s). Model: ShearValve(s). ShearValve(s). Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). 10 ` 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 inspectedlseryiced 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): System set-up report; Alarm history report El PRINTED NAME:DAVID MATHIE SIGNATURE: COMPANY: Tanknology PHONE NO: (800)800-4633 page 1 of 3 Based on CA form dated 03101