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MONIAUNG SYSTEM CERTIFATION RECEIVED For Use By All Jurisdictions Within the State of California (((( 7 O,O Authority Cited:Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Id(i This form must be used to document testing and servicing of monitoring equipment. A separate certification or report anus6banaaearedrfor0 ru monitorine;ystem control panel by the technician who performs the work. A copy of this form must be provided to the tank� Mr. 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 Facility Name: Charter Way Chevron Bldg.No.: Site Address: 508 Charter Way City: Stockton, CA. Zip: 95206 Facility Contact Person: Rinku Contact Phone No.: (209) 4653440 Make/Model of Monitoring System: Veeder-Root TLS-350 Date of Testing/Servicing: 1 011 312 01 0 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates ific Muipment inspected/serviced. Tank ID: T7: 87 Tank to: T2: 91 ❑In-Tank Gauging Robe. Model: ❑In-Tank Gauging Probe. Model: N Annular Space or Vault Sensor. Model: 794390-420 N Annular Space or Vault Sensor. Model: 794390-420 N Piping Sump/Trench Sensor(s). Model: 794380-208 N Piping Sump/Trench Sensor(s). Model: 794380-208 ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑Mechanical Line leak Detector. Model: ❑Mechanical Line Leak Detector. Model- 0 Electronic Line leak Detector. Model 8484 N Electronic Line Leak Detector. Model: 8484 ❑Tank Overfill/High-Level Senses. Model: ❑Tank Overfill/Higb-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). Tank ID: T3: Diesel Tank ID: ❑In-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: N Annular Space or Vault Sensor. Model: 794390420 ❑Annular Space or Vault Sensor. Model: N Piping Sump/Trench Sensor(s). Model: 794380-208 ❑Piping Sump/Trench Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: N Electronic Line Leak Detector. Model: 8484 ❑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 ID: 1&2 Dispenser ID: 384 ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: N Shear Valve(s). ®Shear Valve(s). N Dispenser Containment Float(s)and Chain(s). N Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5&6 Dispenser ID: 7&8 ❑Dispenser Containment Sensm(s). Model: ❑Dispenser Containment Sensor(s). Model: N Shear Valve(s). N Shear Valve(s). N Dispenser Containment Floats)and Chain(s). N Dispenser Containment Flost(s)and Chain(s). Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: ❑Shear Valve(s). ❑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 -►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 Plot Plan showing the layout of monitoring equipment For any equipment capable of generating such reports,I have also attached a copy of the report;(check all that apply): ®System set-up ® Alarm history report Technician Name(print): Guadalupe Sanchez Signature: Certification No.: A30138 License.No.: 883706 Testing Company Name: Reliable Petroleum Services, Inc. Phone No.:(209) 845-8586 Testing Company Address: 521 Branding Iron St. Oakdale,CA. 95361 Date of Testing/Servicing: 10/1312010 Page 1 of 4 Rev(2/08)