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i MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safely Code; Chapter 16,Division 3, Title 23, California Code of Regulations toting equipment.A separate re ared This form must be used to document testing and servicing of mom of artareporttion or s form mustbe protvtded toust bet he tank for each monitor' o vstem control panel by the technician who performs the work. A copy 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 Bldg.No.: Facility Name: Chevron StationCiTy' 9534.7 Tracy, CA Zip: Site Address: 3400 Mac Arthur Blvd. X209 834-1220 Facility Contact Person: Kulwinder Singh Contact Phone No.: Make/Model of Monitoring System: eder—Root TLS-350 Date of Testing/Servicing: p3 122_/OS B. Inventory of Equipment Tested/Certified F-k a ro nate boxes to indicates ecince ui ment ins eeted/serviced:F- Diesel Re alar : n/,7100-109k Gauging Probe. Model:�k Gauging Probe. Model:�o.�--- 794380-302 ar Space or Vault Sensor. Model: 7°t'°an-302ar Space or Vault Sensor. Model: 7o/ 'tnn_70R7o/.4R0-208 Sump/TrenchSensor(s). Model:Sump/Trench Sca sor(s). Model:�v-z —20— Model: 794380-208ump Scnsor(s). Model: 7o%'ABQ-708mp Sensor(,).nical Line Leak Detector. Model: �anical Line Leak Detector. Model: LD200_0 onic Line Leak Detector. Model: ronic Line Leak Detector. Medd:______vTanOverfill(High-Level Sensor. Model:j;r Overfill/High-Level Sensor. Model: r'14tpo41 (" O Other s eci equipment t e and model in Section E on Page 2 . ❑ Otherspecifyequipment a and model m Section E on Pae 2). Tank lD: Premium Tank lD. ❑ In-Tank Gauging Probe. Model: a 3' 90-109 ❑ In-Tank Gauging Probe. Model: 0 Annular Space or Vault Sensor. Model: 794zan-402 ❑ Annular Space or Vault Sensor. Model: O Piping Sump/Trench Sensor(s). Model: 7o/,2an_70R ❑ Piping Sump/Trench Sensor(,). Model: O Fill Sump Sensor(,). Model: 7o/ as2n_7DR ❑ Fill Sump Sensor(s). Model: El Mechanical Line Leak Detector. Model:r D2 nn0 ❑ Mechanical Line Leak Detector. Model: ❑ Electionic Line Leak Detector. Model: tJ Electronic Lint Leak Detector. Model: p Tank Overfill!High-Level Sensor. Model: f Tank Overfill/High-Level Sensor. Model: ❑ Other(s eci c ui mcnt type and model in Section E on Pa e 2 . ❑ Others eci a ui ment type and model in Section E on Pa e 2 . Dispenser ID: 3/4 Dispenser FD: 1/2 7ot.?nn_70A ❑ Dispenser Containment Sensor(,). Model: 794380-208 O Dispenser Containment Sensm(s). Model: -�---- 0 Shear Valve(s). (3 Shear Valve(s)— C3Dis enser Containment Floats and Chains . C! Dis enser Containment Float(s)and Chain s). Dispenser[D: 7 8 —08 Dispenser er 5/6 ❑ Dispenser Containment Sensor(,). Model: 794380_ 2O8 Q Shear Vrd e(s�tainment Sens r(s). Modelr 7943 0-2 a Shear Valve(s). ❑ Dis enser Containment Floats and Chain(s). ❑ Dispenser Containment Float s and Chain.s . Dispenser ID: Dispenser ID: ❑ Dispenser Containment Scnsor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear V alve(s). ❑ Dis enser Containment Floats and Chains . ❑Dis enser Containment Floats and Chains . •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 documenify that this information Is t was inspected serviced in accordance with the manufacturer s guidelines. Attached to this Certification is information (e.g. manufacturers' checklists).necessary to ver correct and a Plot Plan showing the layout of monitoring equipment. For any equipment cap le of generating such reports,l have also attached a copy of the report;(check all that apply): ®System set-up Alarm h' ory re ort Technician Name(print): Gre R. Geltz Signature: License.No.: 491448 Certification No.: Testing Company Name: Central Petroleum Maintenance Co. Phone No.:�925 462-4060 3400 MacArthur Blvd. , Tracy, CA Date of Testing/Servicing:03_4L_/9_5 Site Address: R Page 1 of 3 Rev.06104101 UN-036-1/4 w,vw.unidocs.org