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MAY -23-2012 11:09 Service Station Systems 408 938 8888 P.02 MonitoriN� System Equipment A For Use By All Jurisdictions Within The State of Cali farnia Authority Cited: Charter 6.7, Health and Safely Code; C'hoplee 16, Division 3, Tille :3, C:ulifornia Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or noxt-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 Bldg. No.: Site Address: 10858 Trinity Pkwy City: Stockton, CA Zip: 95219 - Facility Contact Person: Pauline; Contact Phone No.: (209) 952.2213 Make/Model of Monitoring System: V/R TLS -350 S. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Date of Testing/Servicing: 511112 Tank ID: 01-Regu Tank ❑ 111' 02 -Prom in - Tank Gauging Probe. Model: VR 247390.109 Q In -Tank Gauging Probe. Model: vq $47390.109 Q Annular Space or Vault Sensor. Model: VR 794380.303 (] Annular Space or Vault Sensor. Model; VR 794380.303 Q Piping Sump 1 Trench Sensor (s). Model: VR 794380-20$ ❑ Piping Sump 1 Trench Sensor (s), Model: VR 794380.208 ❑ Fill Sump Sensor (s). Model: VR x94390.209 ❑ Fill Sump Sensor (s). Model: VR 794980.208 ❑ Mechanical Linc Leak Detector. Model: Mechanical Line Leak Detector. Model: [] Electronic Line Leak Detector. Model: VR Sense 8484 {] Electronic Line Leak Detector. Model: vR Series 8484 C Tank Overfill 1 High -Level Sensor. Model: ❑ Tank Overfill \ High4.cvcl Scnsor. Model: ❑ Other ( specify equipment type and model in Scction F on Page 2). Q Other (spwity equipment type and model in Section E on Page 2). Tank TO; 03•olesel Tank ❑ IQ, In -'fink Gauging Probe. MWD; ❑ In - Tank Ciauging Probe. Model: VR 847390.109 C) Annular Space or Vault Sensor. Model: VR 794380-303 ❑ Annular Spacc or Vault Sensor. Model: ❑ Piping Sump 1 Trench Sensor (s), Model: vR 794300.208 p Piping Sump 1 Trench Sensor (a). Model: ❑ Fill Sump Scnsor (s). Model: VR 794380.208 ❑ Fill Sump Sensor (s). Model: El Mechanical Line Leak Detector. Model: ❑ Mechanical Line Lizuk D woor. Model: all Electronic Line Leak Detector. Model: VR $orws 9494 ❑ Flectronic Linc Leak Detector. Model: ❑ Tank Overfill \ High -Level Sensor. Model: Q Tank Overfill 1 High -Level Sensor, Model; C] Other ( specify equipment type and model in Section L on Page 2). ❑ Othor ( specify egt,ilyuwnt tyre and model in Section F on Page 2). Dispenser ID: 01.02 Dispenser ❑ 1D' 03-04 Dispenser Containmetn Sensor (s), Modcl: vR 7943$9.20$ [j Dispenser Containment Sensor (s). Model: VR 794980-208 C] Shear Valve (s). ❑ Sheat' Valve (s). 0 Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser TD: 05-06 ❑ Dispenser Containment Sensor (.$), Model: VR 794390-20s Dispenser ID: 02.09 C7 Dispenser Containment Sensor (s). Model; VR 7943410-208 Q $bear Valve (g). ❑ Shcar Valve (s). [) Dispenser Containment Float (5) and Cltaln (,$), © Dispenser Containment Float (s) and Chain (s). Dispenser ID: 09.10 ____--- Dispenser ID; 11.12 ❑ Dispenser ('Ontainrncnl. Sensor (E), Model: VR 794390.208 Q Dispenser Containment Sensor (s). Model: VR 794380-206 ❑ Shear Valve (a). ❑ Shear Valve (s)- ❑ Dispenser Containment Float(s)and Chain (s). Dispenser Containment Float (s) and Chain (s), 41fthe facility contains more tanks or dispensers, copy this form. Include infOnnation for every tank and dielxytser at the facility C. Certification - J certify that the equipment identified let this document was inspected/serviced in accordance with the manufacturer's guidelines. Attnclled to this Certification is information (e.g. manufactures' checklists ) accessary to verify that this Information Is correct and a Plot Pian showing the layout of monitoring equipment. For any equipment chpable of generating such reports, l have also attached a copy or the; (check all thatappW. p System set-up 0 Alarm history report Technician Name (print): Randy Wilkerson Mfg. Ccrtd i.: A32404 ICC# 5258560 -UT Signature:&�L License. No.: 485184 Testing Company Name: Service Station Systems Phone No.: (408) 971-2445 Testing Company Address: 680 Quinn Ave., San Jose, CA 95112 Date of Testing/Servicing: 5/1112