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RECEIVE[ MONITORING SYSTEM CERTIFICATION FEB 17 2016 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 Tj This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must ENT 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: CNP Stocton Site Address: 3330 N. Ad Art Rd. Facility Contact Person: Linh Make/Model of Monitoring System: TLS -350 B. Inventory of Equipment Tested/Certified r1l. 1, t6n n..n..n...datn hn to iedinute S recon anninmant insn"ted/wrvir0d! Bldg. No.: City: Stockton Zip: 96215 _ Contact Phone No.: (209) 943-8666 Date of Testing/Servicing: 1/1912016 Tank ID: 87 Tank ID: ® In -Tank Gauging Probe. Model: VR -Mag ® In -Tank Gauging Probe, Model: ® Annular Space or Vault Sensor. Model: VR 420 ® Annular Space or Vault Sensor. Model: ® Piping Sump / Trench Sensor(s). Model: VR 208 ® Piping Sump / Trench Sensor(s). Model: ® Fill Sump Sensor(s). Model: VR 208 ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: FE PETRO ® Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: FLAPPER ® 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). Tank ID: Tank ID: ® In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ® Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® 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: 112 Dispenser ID: ® Dispenser Containment Sensor(s). Model: VR 208 ❑ 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: 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). *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 Piot 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 Technician Name (print): Robert S. Carr Signature: t�s,.//,� .g.. E,2_� Certification No.: 8340716 License. No.: 872234 Testing Company Natne: Rumex Construction Corp Phone No.: (559) 271-3300 Testing Company Address: 3755 W. Gettysburg Ave., Fresno, CA 93722 Date of Testing/Servicing: 1/19/2016 Page 1 of 3 Rev (2/08)