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MONITNG SYSTEM CERTIFICAN F By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Neal and Safety Code; Chapter 16, Division 3 Title 23, Californ Code of Regulations This form must be used to document testing and servicing of monitoring equipment. If more than one monitoring system control panel is installed at the facility, 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 ownertoperator. The ownerloperator must submit a copy of this forth to the local agency regulating LIST systems within 30 days of test dale, A. General Information Facility Name: CHEVRON 210997 (N-4693) Site Address: 1442A COLONY DR. Facility Contact Person: PATTY Make/Model of Monitoring System: TLS 350 B, Inventory of Equipment TestedlCertifted Check the appropriate boxes to indicate specific equipment inspectedlserviced City: RIPON Contact Phone No: 599-0149 Date of TestinglService: 0210712011 Work Order Number: 2279400 CA Zip: 95366 Tank ID: SUPREME Tank ID: REGULAR X In -Tank Gauging Probe. Model: MAG X In -Tank Gauging Probe. Model: MAG 91 Annular Space or Vault Sensor. Modei: 409 Annular Space or Vault Sensor. Model: 409 _R1 Piping Sump/Trench Sensor(s). Model: 208 Piping Sump/Trench Sansor(s). Model: 208 X Fill Sump Sensor(s). Model: 2 Fill Sump Sensor(s). Model: 208 Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: X Electronic Line Leak Detector. Model: PLLD %( Electronic Line teak Detector. Model: PLLD X Tank OverfilllHigh-Level Sensor- ModeC EXTERNAL ALARM Tank Overfill/High-Level Sensor. Model: EXTERNAL ALARM 71 Other (specify equipment type and model in Section E on page 2). Other (specify equipment type and model in Section E on page 2). TanklD: TanklD: 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 SumplTrench Sensor(s). Model: Fill Sump Sen50r(5). Model: Fill Sump Sensogs). 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 : 112 Dispenser ID: 314 ® Dispenser Containment Sensors) Model 208 X Dispenser Containment Sensor(s) Model: 208 QX Shear Valve(s). X Shear Valves) QDispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: 516 Dispenser ID: 718 ® Dispenser Containment Sensors) Model: 208 X Dispenser Containment Sensors). Model: 208 Shear Valve(s). ® Shear Valve(s). Dispenser Containmept Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 9110 Dispenser ID: 11112 X❑ Dispenser Containment Sensors) Model: 208 X Dispenser Containment Sensors). Model: 208 Shear Valve(s). X 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 Site Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the (Check all that apply): p System set-up ® Alarm history report Technician Name (print): STEVEN WILLEMS Signature: <5��_ Certification No.: B36743 License. No.: 743160 (Class 'A' General Enginering Contractor License) Testing Company Name: Tanknology Phone No.: (800) 800-4633 Site Address: 11000 N. MoPac Expressway, suite 500, Austin, TX 78759 Date of TestinglServicing: 02/07/2011 Monitoring System Certification Page 1 of 3 Based on CA form dated 03108