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• (Copies of Monitoring system Certification For Use Authority Cited: Chapter 6.7, Health and, Regulations This form must be used to document testing and servicing of panelsystem control performs the ,, ownerr/opemtormust submit tachnician o copy of this form to the local A. General Information Facility Name: CHEVRON 210997 (N-4693) Site Address: 1442A COLONY DR. Facility Contact Person; pATTy Make/Model of Monitoring System: Veeder Root TLS -350 B. Inventory of Equipment Tested/Dertinod Tank ID: T1:SUPREME UNLEADED - PREMIUM Wo In -Tank Gauging Probe. r In -Tank Gauging Probe. P Annular Space or Vault Sensor. Model: mag Piping Sump / Trench Sensor(s). Model: 409 Model: Fill Sump Sensor(s). 209 r Mechanical Line Leak Detector. Model: 209 Electronic Line Leak Detector. Model: (7 Tank Overfill / High Model:Veeder Root PLLC -Level Sensor. Model: fiaooer/ext alarm Tank ID: V In -Tank Gauging Probe. r In -Tank Gauging Probe. Model : r Annular Space or Vault Sensor. Model: r Piping Sump / Trench Sensor(s). Model: Model: r Fill Sump Sensor(s). A r Mechanical Line Leak Detector. Model: r Electronic Line Leak Detector. Model: r Tank Overfill Model: / High -Level Sensor. Model: Dispenser 1 ID: /2 j7 Dispenser Containment Sensor(s). Shear Valve(s). 5/6 ID: P Dispenser Containment— PO Shear Valve(s). Dispenser ID: g/10 j7 Dispenser Containment Sensor(s). Model: 209 Shear Valve(s). more tanks or dispensers, copy Appendix VI 40 REGEivF.L and UST Monitoring Plot Plan available at http://www.gwfdb.ca.gov 'SYSTEM CERTIFICATION F'EB 2 3 2016 wsdictions Within Me State ofCaiiPomia CA' p Code; Chapter 16, Division 3, Title 23, Ca/iforniSEbl��f:70NMENTAL HHH DI u r1C06i2TAaCkrT iboring equipment. A separate certification or report most be prepared for each monitoring mpy of this form must be provided to the tank system owner/operator. The y regulating UST systems within 30 days of test date, City: RIPON Phone No.: 203599-014g Bldg, No.: Zip: 953% Date Of Testing/Servicing: 1/21/2016 Tank ID: T2: REGULAR UNLEADED - REGULAR V In -Tank Gauging Probe. r In Gauging Probe. Model : r Annular Space or Vault Sensor. Model: mag 409�� Piping Sump / Trench Sensor(s). Model: Model: A I✓ Fill Sump Sensor(s). Model: Model: � Mechanical Line Leak Detector, Model: Model: 209 7 Electronic Line Leak Detector. 7 Model :Veeder Root PLLD Tank Overfill / High -Level Sensor. Model: faooer/exfaer a Tank ID: r In Gauging Probe. Model : r Annular Space or Vault Sensor. — Model: r Piping Sump /Trench Sensor(,). — Model: r Fill Sump Sensor(s). — r Mechanical Line Leak Detector. Model: Model: r Electronic Line Leak Detector. Model: r Tank Overflll / High -Level Sensor. Model: Dispenser ID: 3/4 P Dispenser Containment Sensor(,). Model: 209 P Shear Valve(s). ID:�••:7/8 F Dispenser Containment Sensor(s), Model: PO Shear Valve($). 11/12 W1 Dispenser Containment Sensor(s). Model: 209 r Shear Valve(s). �— ie ,dcmry. C. Certification- I certify that the equipment identified in this document as inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certifcabon is information (e.g. manufacturers' checklists) necessary t verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such re rts, I have also attached a copy of the report; (check all that appiyy 9 System set- up rglarm history report Technician Name (print): larrod Cooke Certification No.: 635255 Testing Company Name: Tanknology Testing Company Address: 11000 N. MOPac Monitoring System Certification License, Suite 500 _ Signature: 743160 Class'A' Phone No.: (800) 600-0633 Date of Testing/Servicing: 1/21/2016 12/07