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MONITORING SYSTEM CERTIFICATION 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 of Regulations 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 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 LIST systems within 30 days of test date. A. General Information Facility Name: Ryder Bldg. No.: Site Address: 3633 Duck Creek Rd. City: Stockton Zip: 95215 Facility Contact Person: Contact Phone No.: (209) 943-3218 Make/Model of Monitoring System: Veeder-Root TLS -350 Date of Testing/Servicing: 1/1612009 B. Inventory of Equipment Tested/Certified Ch k th . t b c to indicate s ecilic et ui mment ins ected/serviced: ec e a ro na a oxe if I Tank ID: TI: Diesel Tank ID: T2: Diesel Reserve ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: • Annular Space or Vault Sensor. Model: 0794390-420 ® Annular Space or Vault Sensor. Model: 0794390-420 ® Piping Sump f Trench Sensor(s). Model: 0794380-205 ® Piping Sump / Trench Sensor(s). Model: 0794380-205 ® Fill Sump Sensor(s). Model: 0794380-208 ® Fill Sump Sensor(s). Madel: 0794380-208 Z Mechanical Line Leak Detector. Model: 99LD2000 ® Mechanical Line Leak Detector. Model: 99LD2000 ❑ Electronic Line Leak Detector. Madel: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill I High -Level Sensor. Madel: ❑ Other (specify equipment type and model in Section F on Page 2). ❑ Other (specify equipment type and model in Section fi on Page 2). Tank ID: T3: New Oil Tank ID: T4: Used Oil Z In -Tank Gauging Probe. Model: 0 In -Tank Gauging Probe. Model: 846391-603 ® Annular Space or Vault Sensor. Model: 0794390-420 ® Annular Space or Vault Sensor. Model: 0794390-420 • Piping Sump I Trench Sensor(s). Model: 0794380-208 0 Piping Sump I Trench Sensor(s). Model: 0794380-208 ® Fill Sump Sensor(s). Model: 0794380-208 Z Fill Sump Sensor(s). Model: 0794380-208 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 I High -Level Sensor. Model: Ej 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 ID: 1/2 Dispenser ID: 314 0 Dispenser Containment Sensor(s1. Model: 0794380-208 0 Dispenser Containment Sensor(s). Model: 0794380-208 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment lli5at(s) and Chain(.$). ❑ Dispenser Containment Hoat(s) and Chain(s). Dispenser ID: 1 Dispenser ID: 4 Z Dispenser Containment Sensor(s). Model: 0794380-208 ® Dispenser Containment Sensor(s). Model: 0794380-208 Z Shear Valve(s). ® Shear Valve(s). Dispenser Containment Floatf. o and Chain(s). ❑ Dispenser Containment hloa6(s) and Chain(s). Dispenser ID: 2 Dispenser ID: 0 Dispenser Containment Sensor(s). Model: 0794380-208 ❑ Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). *If the facility contains more tanks or dispenser, 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 Plot Plan showing the layout of monitoring equipment. For any equipment capable or generating such reports, I have also attached a copy of the report; (check all that apply): Z System set-up Alarm history report Technician Name (print): Robert Henninger Signature: Certification No.: A25027 License. No.: 396757 Testing Company Name: Balch Petroleum Testing Company Address. SM Ames Ave Page I of 4 Phone No.: (408) 942-8686 Date of Testing/Servicing: 1/16/2009 CP 406—IA wwwunidocsAwp Illim9IWAM