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MAY -23-2012 11:11 Service Station Systems 408 938 e88e F.07 Monitorivi System Equipment A Y For U.ce By All Jurisdictions Within The State. of C:'alifornia Authority Cited: Chapter 6.7, Health and Safeay 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 cettihcation or reportmust be prepared for each monitoring system_c!�ptrol panel by the technician who performs the work, A copy of this form must be provided to the tank systetn owncr/operator. Tire 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_Pkn City: Stockton, CA Zip: 95219 - Facility Contact Person: Pauline Contact. Phone No.: (209) 952-2213 Make/Model of Monitoring System: V/R TLS -350 Date of Testing/Servicing: 518112 13. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID' 01-Requ Tank In! 02 -Prem ❑ In - rank Gauging Probe. Model VR 847390-+05 ❑ In - Tank Causing Probe. Modal: VR 947390.109 ❑ Annular Space or Vault Sensor, Model: VR 794380.303_ ____ ❑ Annular Space or Vault Sensor, Model: VR 71t438o-303 ❑ Piping Sump 1 Trench Sensor (s). Modcl. VR 794300-208 ❑ Piping, Sump 1 Trench Sensor (s). Model: VR 754390.208 ❑ Fill Sump Sensor (s). Model: VR 794390208 ❑ Fill Sump Scnsor (a). MM1Ci: VR 704380.209 _ 0 Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Deeaor. Model_ _ ❑ Electronic Line Leak Detector. Model, VR Eariee 8484 ❑ Electronic Line Leak Detector, Model: VR $erbs 9484 p Tank Overfill 1 High -Level Sensor. Model: ❑ Tank Overfill '\ Iiig)l-Level Sensor. Model: p Other ( specify equipment type and model in Section L on Page 2), ❑ Other ( specify equipment type and model in Section F on Page 2). Tank Ill• 03-Dlesel Tank ID- _— ❑ In - Tank Gauging Probe. Model: VR 947390.109 _ _ ❑ In - Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor, Model: VR 794390-303 ❑ Annular Space or Vault Sensor. Model: [3 Piping Sump 1 Trench Sensor W. Model: VR 794390.208 ❑ Piping Sump 1 Trench Sensor (s). Model: C] Fill Sump Sensor (s)- MM1ch VR 754380.209 p Fill Sump Sensor (s), Model: ❑ Mechanical Line Leak Detcaor. Model: ❑ Mechanical Line Leak Detector. Model. Electronic Line Leak Detector. MVdeL' VR Series 9484 p Flectronic Line Leak Detector, Model: [7 Tank Overfill t High -Level Sensor, Model: ❑ Tank Overfill 1 high -Level Sensor. Model: ❑ Other ( specify equipment type and model in Section L' on Page 2). Other ( specify equipment typo and model in Section F on Page 21). III;01'02 _ Dispenser ID- 03-04nser FDenser Containment Sensor (s), Model: VR 194280.208 ❑ DisperutcrContainmentSensoN'(R). Model: VR 794980-208 Valve (s). ❑ Shcar Valve (s). nser Containment Float (s) and Chain (s)- p Dispenser Containment Float (s) and Chain (s). Dispenser ID- 05-06 _ Dispenser ID: 07.00 ❑ Dispenser Containment Sensor (s). Model:_ VR 794380.208 p Dispenser Containment Sensor (R). Model: VR 794380-209 p Shear Valve (s). ❑ Shear Valve (s). ❑ Dispense!' Containment Float (s) and C:haiti (s). ❑ Dispenser Containment I'IVut. (s) acid Cham (s). Dispenser IDS 09-10 _ Dispenser In- 11-12 ❑ Dispenser Containment Sensor (s). Model: VR 794380.208 ❑ Dispenser Containment Sensor (s). Model: VR 794380-209 ❑ Shear Valve (a). R Shear Valve (s), ❑ Dispenser- Containment. Float (s) and Chain (s). ❑ Dispense Containment Moat (s) and Chain (s). *Ifthe facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser atthe facility C, Certification - I certify that the equipment identified in this document was inspccted/serviced in accordance with the manufacturer's guidelines. Attached to this Certification Is information (e.g. m9naf2ctures' checklists ) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of gcner9ting such reports, I have also attached a copy of the; ( check sH Matapply): ❑ System set-up ❑ Alarm history report Technician Name (print): Myke Briggs Signature: Mfg. Cert.#.: B38235 ICC# 8033115 -UT 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; 518!12