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From: 0 01116009 15:43 #328 P.0021005 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 Regulalions 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 Hanel 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. Hyder Bldg. No.: Site Address: 3633 Chuck 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: 111612009 B. Inventory of Equipment Tested/Certified Check the aoorooriate boxes to indicate specific equipment inspectedtserviced: Tank 1D: T1: Diesel Tank ID: T2: Diesel Reserve ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: Z Annular -Space or Vault Sensor. Model: 4794390-420 ( Annular Space or Vault Sensor. Model: 0794390-420 Z Piping Sump / Trench Sensor(s). Model: D794380-205 ® Piping Sump t Trench Sensor(s). Model: 0794380-205 ® Fill Sump Senscu(s). Model 0744380-208 ®s=ill Sump Sensor(s). Model: 0794380-208 (� Mechanical Line Leak Detector. Modc1: 99LD2000 ® Mechanical Line Leak Detector. Model: 99LO2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill t High -Level Sensor. Model: ❑ Tank Overfill / High-level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). (specify equipment type and model in Section E on Page 2i. Wank ID: T3: New Oil Tank ID: T4: Used Oil Z ht -Tank Gauging Probe. Model- ® hi -Tank Gauging Pmbc. Model: 846391-603 ® Annular Space or Vault ,Sensor. Model: 0794390-420 Z Annular Space or Vault Sensor, Model: 0794390-420 ij Piping Sump / Trench Sensor(%). Model: 0794380.208 M Piping Sump t Trench Sensor(s). Model: 0794380-208 ® fill Sump Sen%or(s). Model: 0794380.208 Z Fill Sump Sensorfs). Model: 0794380-208 ® Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector, Model: ❑ Electronic Line Leak Detector. Model: ❑ Flectronic Line Leak Detector. Model: ❑ Tank Overfill t High -Level Sensor. Model: ❑ Tank Overfill / High -Levet Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section F: on Page 2). Dispenser 1D: 112 Dispenser ID: 3/4 Z Dispenser Containment Sensor(s). Model: 0794380-208 Z Dispenser Containment Sensor(s). Model: 0794380-208 ® Shear Vaive(s). ® Shear Valve(s), ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chai i(s). Dispenser ID: 1 Dispenser ID: 4 Z Dispenser Containment Sensnr(s). Model 0794380-208 ® Dispenser Containment Sen.eOr(s). Model- 0794380-208 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Floats) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 2 Dispenser ID: ® Dispenser Containment Sensor(s). Model: 0794380-208 ❑ DispenserContainnient Sensor(s). Model: Z Shear Vaive(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Floats) and Chain(s). TIf 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 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): ® System set-up 0 Alarm history report Technician Name (print): Robert Henninger Signature: Certification No.: A25027 License. No.: 396757 Testing Company Name: Balch Petroleum Phone No.: (408) 942-8686 Testing Company Address: 930 Arises Ave Date of Testing/Servicing: 1116/2009 Page 1 of 4 UN -036 — 114 wwvr,tmidoesorg Rev. 111/17/08