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MONI�RING SYSTEM CERTIF TION RECE v ED For se By All Jurisdictions Within the State of coli ornia 2 d Z��9 Authority Cited. Chapter 6.7,Health and Safety Code, Chapter 16,Division 3, Title 13, California Code 0%V e ons This form must be used to document testing and servicing of monitoring equipment. A separate certification or repoE.W�6L�'Yit�W Ytir� monitoring system control Panel by the technician who performs the work A copy of this forth must be provided to the tar Wb1}u 6" r. 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 FacilityName: CHARTER WAY CHEVRON Bldg.No.: Site Address: 508 W. Charter Way City: Stockton CA Zip: 95206 Facility Contact Person: Surinder Singh Saini Contact Phone No.: (209) 465-3440 Make/Model of Monitoring System: Veeder Root TLS-350 Date of Testing/Servicing: 10/22/2009 B. Inventory of Equipment Tested/Certified Check the approvriate boxes to indicatespecific a ui ment inspected/serviced: Tank ID: T1: 87 Tank ID: T2: 91 ❑In-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: ®Annular Space or Vault Sensor. Model: 794380-420 ®Annular Space or Vault Sensor. Model: 794380.420 ®Piping Sump/Trench Smsor(s). Model: 794380.208 ®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: ®Electronic Line Leak Detector. Model: 8484 ®Electronic Line Leak Detector, Model: 330376.002 ❑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). Tank ID: T3: Diesel TankrD: ❑In-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: ®Annular Space or Vault Sensor. Model: 794380-420 ❑Annular Space or Vault Sensor. Model: ®Piping Sump/Trench Sensor(s). Model: 794380-208 El Piping Sump/Trench Sensor(s). Model: [I Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ®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: 112 Dispenser ID: 314 ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: ®Shear Valve(s). ®Shear ser Containment ®Dispenser Containment Floats)and Chein(s). ®Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5/6 Dispenser ID: 718 ❑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). 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 Cham(s). 'If the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility. C. Certifll,atiOn -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 Plot Plan showing the layout of monitoring a uipment" For any equipment capable of generating such reports,I have also attached a copy of the report;(check all that apply): a System set-up ❑ Alarm history report Technician Name(print): Robert Barnhart Signature: I)fldk_ky�ha Certification No.: B35969 License.No.: 983706 Testing Company Name: Reliable Petroleum Service Inc Phone No.:(209) 845-8586 Testing Company Address: 521 Branding Iron Street Oakdale CA 95361 Date of Testing/Servicing: 10/22/2009 Page 1 of 4 UN-036—1/4 www.unidocs.org Rev.01/17/08