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0 • Addendum to Page _J,, Part Facility Name: Country Club 76 Bldg. No.: Site Address: 2175 Country Club Blvd City: Stocton Zip: 95204 Facility Contact Person: Make/Model of Monitoring System: Inspector: Garrett Veeder Root TLS350 Contact Phone Date of ❑ Not Present ® Present 5/19/2009 Dispenser ID: Fill Sump ANN 87 Dispenser ID: Full Sump Ann 91 Z Dispenser Containment Sensor(s). Model: 420 Z Dispenser Containment Sensor(s). Model: 420 ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Fill sump ANN DIE Dispenser ID: STP ANN 87 Z Dispenser Containment Sensor(s). Model: 420 Z Dispenser Containment Sensor(s). Model: 420 ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: STP ANN 91 Dispenser ID: Stp ANN DIE Z Dispenser Containment Sensor(s). Model: 420 Z Dispenser Containment Sensor(s). Model: 420 ❑ 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 dispensers, cony this form. Include information for every tank and dis enser at the facility. Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: ser ID: ❑ Dispenser Containment Sensor(s). Model: FF�_]DispenserContainment Sensor(s). Model: ❑ Shear Valve(s). ❑Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). 11 t110 la"luty "Umallls More LWIKs or ulspensers, copy tms rorm. tncivae miormation tot every tank and dispenser at the facility. 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 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 ❑ Alarm history report *-�&xVe tjy ctYYet� tns� Technician Name (print): Felix G. Ramirez #5273934 Exp. 06/21/10 Signature: Date of Testing/Servicing: 5-19-09 Phone No.: --)- 0-�z