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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 Cone; 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 UST systems within 30 days of test date. A. General Information Facility Name: Ryder Truck Rental Bldg. No.: Site Address: 3633 Duck Creek Rd. City: Stockton Zip: 95215 Facility Contact Person: James Shannon Contact Phone No.: (209) 943-3213 Make/Model of Monitoring System: Veeder-Root TLS -350 Date of Testing/Servicing: 1/9/2014 B. Inventory of Equipment Tested/Certified Check the anorooriate boxes to indicate.nreifir en-in—t in%n tad/ea i-i Tank ID: T1: Diesel Tank ID: T2: Diesel Reserve Q In -Tank Gauging Probe Model ❑ In -Tank Gauging Probe. Model: N Annular Space or Vault Sensor. Model: 0794390-420 N Annular Space or Vault Sensor, Model 0794390-420 N Piping Sump / Trench Sensor(s), Model: 0794380-206 N Piping Sump/ Trench Sensor(s). Model: 0794380-205 N Fill Sump Sensor(s). Model: 0794380-208 N Fill Sump Sensor(s). Model: 0794380-208 N Mechanical Line Leak Detector. Model: 99LD2000 N Mechanical Line Leak Detector. Model: 99LD2000 ❑ 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 21 ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: T3: New Oil Tank ID: T4: Used Oil ® In -'rank Gauging Probe. Model: ® In -Tank Gauging Probe Model: 848391.603 ® Annular Space or Vault Sensor. Model: 0794390-420 ® Annular Space or Vault Sensor. Model: 0794390-420 ® Piping Sump / Trench Sensor(s) Model 0794380-208 ® Piping Sump / Trench Sensor(s). Model: 0794380-208 ® Fill Sump Sensor(s). Model: 0794380-208 ® Fill Sump Sensor(s). Moder 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 / 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). Dispenser ID: 1/2 Dispenser 1D: 3/4 ® Dispenser Containment Sensor(s). Model 0794380-208 N Dispenser Containment Sensor(s). Model: 0794380-208 N Shear Valve(s). N Shear Valve(s). ❑ Dispenser Containment Float(s) and Chair( s r ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 1 Dispenser 1D: 4 N Dispenser Containment Sensor(s). Model 0794380-208 N Dispenser Containment Sensor(s). Model: 0794380-208 N Shear Valve(s). N Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s) ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 2 Dispenser ID: N Dispenser Containment Sensor(s) Model: 0794380-208 ❑ Dispenser Containment Sensor(s). Model: N Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Floa(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/seryiced 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 applv): ® System set-up N 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 Ames Ave., Milpitas, CA 95035 Date of Testing/Servicing: 1/9/2014 Page 1 of 4 I N-036 -1/4 www.unidocs.org Rev. 01/17/08