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Monitoring System Equipment 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 UST system within 30 days of test date. A. General Information Facility Name: Chevron Site Address: 10858 Trinity Pkwy Facility Contact Person: Pauline Make/Model of Monitoring System: V/R TLS -350 B. Inventory of Equipment Tested/Certified Check the aonronriste boxes to indicate specific enuinment insnectedfserviced: Bldg. No.: City: Stockton, CA Zip: 95219 - Contact Phone No.: (209) 952-2213 Date of Testing/Servicing: 5/8112 Tank ID: 01-Regu Tank ID: 02 -Prem ❑ In - Tank Gauging Probe. Model: VR 847390.109 ❑ In - Tank Gauging Probe. Model: VR B47390-109 ❑ Annular Space or Vault Sensor. Model: VR 794380.303 ❑ Annular Space or Vault Sensor. Model: VR 794380.303 ❑ Piping Sump \ Trench Sensor (s). Model: VR 794380.208 ❑ Piping Sump \ Trench Sensor (s). Model: VR 794380.208 ❑ Fill Sump Sensor (s). Model: VR 794380-208 ❑ Fill Sump Sensor (s). Model: VR 794380.208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: VR series 8484 ❑ Electronic Line Leak Detector. Model: VR series 8484 ❑ 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). Tank ID: 03 -Diesel Tank ID: ❑ In - Tank Gauging Probe. Model: VR 847390.109 ❑ In - Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: VR 794380.303 ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump \ Trench Sensor (s). Model: VR 794380-208 ❑ Piping Sump \ Trench Sensor (s). Model: ❑ Fill Sump Sensor (s). Model: VR 794380-208 ❑ Fill Sump Sensor (s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: VR Series 8484 ❑ 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: 01-02 Dispenser IDS 03-04 ❑ Dispenser Containment Sensor (s). Model: VR 794380.208 ❑ Dispenser Containment Sensor (s). Model: VR 794380-208 ❑ Shear Valve (s). ❑ Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser ID: 05-06 Dispenser ID: 07-08 ❑ Dispenser Containment Sensor (s). Model: VR 794380208 ❑ Dispenser Containment Sensor (s). Model: VR 794380.208 ❑ Shear Valve (s). ❑ Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment FIoat (s) and Chain (s). Dispenser ID: 09-10 Dispenser ID- 11-12 ❑ Dispenser Containment Sensor (s). Model: VR 794380-208 ❑ Dispenser Containment Sensor (s). Model: VR 794380-208 ❑ Shear Valve (s). ❑ Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). *Ifthe 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 inspectedtserviced in accordance with the manufacturer's guidelines. Attached to this Certification is information (e.g. manufactures' 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, 1 have also attached a copy of the; (check aft thatappty): ❑ System set-up ❑ Aillarm history report Technician Name (print): Myke Briggs Signature: "7 t ^} Mfg. Cert.#.: B38235 ICC# 8033115 -UT License. No.: 485184 Testing Company Name: Service Station Systems Testing Company Address: 680 Quinn Ave., San Jose, CA 95112 Phone No.:(408) 971-2445 — Date of Testing/Servicing: 5/8/12