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MONIT ING SYSTEM CERTIFI�TION se By All Jurisdictions Within the State of Calif0mi Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3 Title 23, California 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 monitorincLsystem control panel by the technician who performs the work. A copy of this form must be provided to the tank system awnerloperator. The ownertoperator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information City: STOCKTON CA Zip: 95215 Facility Name: RYDER 1071A Site Address: 3633 DUCK CREEK DR. @ STAGECOACH RD Contact Phone No: 943-3213 OFF HWY 99 @ MARIPOSA RD Date of Testing/Service: 03128/2005 Facility Contact Person: MARK ARMSTRONG Make/Model of Monitoring System:VRTLS350 Work Order Number: 2234627 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspectedlserviced TanklD: 1 TanklD: 2 X In -Tank Gauging Probe. Model: MAG X In -Tank Gauging Probe. Model: MAG X Annular Space or Vault Sensor. Model: 420 Annular Space or Vault Sensor. Model: 420 X Piping Sump/Trench Sensor(s). Model: 205 Piping Sump/Trench Sensor(s). Model: 295 X Fill Sump Sensor(s). Model: I 01 Fill Sump Sensor(s). Model Mechanical Line Leak Detector. Model: LD2000 Mechanical Line Leak Detector. Model: LD2000 Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill/High-Levet Sensor. Model: VEEDER-ROOT X Tank Overfill/High-Level Sensor. Model: VEEDER-ROOT Other (specify equipment type and model in Section E on page 2). Other (specify equipment type and model in Section E on page 2). TanklD; 3 TanklD: X1 In -Tank Gauging Probe. Model: MAG In -Tank Gauging Probe. Model: MAG X Annular Space or Vault Sensor. Model: 420 Annular space or Vault Sensor. Model: 420 X Piping SumpfTrench Sensor(s). Model: 205 Piping Sump/Trench Sensor(s). Model: 208 X Fill Sump Sensor(s). Model: 208 Fill Sump Sensor(s). Model: 208 Mechanical Line Leak Detector. Model: 7Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: X1 Tank Overfill/High-Level Sensor. Model: VEEDER-ROOT X Tank Overfill/High-Level Sensor, Model: VEEDER-ROOT Other (specify equipment type and model in Section E on page 2). Other (specify equipment type and model in Section E on page 2). Dispenser : 1 Dispenser ID: 1S 7XIDispenser Containment Sensor(s) Model 208 X Dispenser Containment Sensor(s) Model: 208 QX Shear Valve(s). X Shear Valves) ElDispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: 213 Dispenser ID: 2S Dispenser Containment Sensor(s) Model: 208 71 Dispenser Containment Sensor(s). Model 208 X� Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: 3 Dispenser ID: EDispenser Containment Sensor(s) Model: 208 Dispenser Containment Sensor(s). Model: ® ShearValve(s). Shear Valve(s), 0 Dispenser Containment Float(s) and Chain(s). 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 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 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): ry 1 System set-upAlarrn history report Technician Name (print): RAYMOND SIMMS Signature: Certification No.: 006-05-0282 License, No.: Testing Company Name:Tanknology Phone No.: (800) 800-4633 Site Address: 8501 N. MoPac Expressway, suite 400, Austin, TX 78759 Date of Testing/Servicing: 03/28/2005 Page 1 of 3 Based on CA form dated 03/01 Monitoring System Certification