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Nov 23 09 10:53a Reliable PetroleumA 209-845-8953 p.2 MONI7CNG SYSTEM CERTIFIPATION ,For Usehe State a Authority Cited. Chapter 6.7, Health a d Safety,411 tCode.- Chapterr 16,thin tDivision 3, Tille 23rCalifornio Code ofRegulatrons This form must be used to document testing and servicing of monitoring equipment. A separate certification pr report must be or ared for each monitormo system control panel by the technician who performs the work. Ai copy of this form must he provided to the tank system owned for each 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 Site Address: 508 W-Chatter Way Bldg.No.: Facility Contact person: Surinder Singh Saini --- City: Stockton CA Zip: 95206 Make Mode] of Monitoring System: Veeder Root TLS-350 Contact Phone No.: 209 465-3440 B, Inventory of Equipment Tested/Certified Date of Testing/Servicing: 1012212009 Check the a ro riate boxes to indicates ecific a ui mart ins ected/serviced: Tank ID: T1: 87 ❑In-Tank Gauging Probe. Tank JD: T2: 91 btodel: ❑In-Tank Gauging Probe. Model: ce or Vault Sensor. Model: 794380-420 ®Annular Spa 0 Piping Sump/Trench Sensor(sl, Model: 794380-208 ®Annular Space or Vault Sensor. Model; 794360 420 EDFiII Sump Sensor(s). Model: ®Piping Sump i Trench Sensor($). Model: 794380.208 ❑Mechanical Line Leak Detector, Model: Q Fill Sump Sensor($). Model; ®Electronic Line Leak Detector. Model: 8484 ❑Mechanical Line Leak Detector. hdodcl: ❑Tank Overfill/High-Level Sensor. Model: ®Electronic Line Leak Detector Model: 330378-002 �tA ❑Other(specify equipment type and mode[in Section E on Page 2). ❑Tank Overfill"High-1,1111 Sensor. Model: ❑Other(specify equipment type and model in Section E on Page 2), Tank ID: T3: Diesel ❑In-Tank Gauging Probe, Tank iD: Model: Annular Space or Vault Sensor. Model: 794360420 ❑[n-Tank Gauging Probe. Model: ®Piping Sump/Trench Semor(s). Model: 794380-208 ❑Annular Space or Vault Sensor. Model: ❑Fill Sump Sensor(,), Model: L3 Piping Sump I Trench Sensor(s). Model: ❑Mechanical Line Leak Detector. Model: ❑Fill Stump Sensor($). Model: ®Electronic Line Leak Detector. Model: 8484 ❑Mechanical Line Leak Detector. Madel: ❑Tank Overfill/High-LevetSenspr. Model: ❑Electronic Line Leak Detector. Model El Other(specify equipment type and model in Section E on Page 2). ❑Tank Overfill/High-Leve!Sensor. Model: Dispenser ID: 112 ❑Other(specify equipment typo and model in Section E on Page 2). ❑Dispenser COntainment Sensor($). Model: Dispenser ID: 314 ®Shear Valve($). ❑Dispenser Containment Sensor(s). Model: ®Dispenser Containment Float(s)and Chain(s). ®Shear Va]vc(s). Dispenser ID: 516 'Z Dispenser Containment Flost(s)and Chain(s). ❑Dispenser Containment Semsor(s). Model: Dispenser ID: 716 Z Shear Valve(s). ❑Dispenser Containment Sensor(,). Model: ®Dispenser Containment Floal(s)and Chain($). Shear Valve(s). Dispenser ID: ®Dispenser Containment Floats)and Chain(s). ❑Dispenser Comamment Sensor(s). Model: Dispenser ID: ❑Shear Valve(s). ❑Dispenser Containment Senso($). Model: ❑Dispenser Containment Float(s)and Chain(s). ❑Shear Valve(,). 'If the facility contains more tanks or dispensers,copy Q Dispenser Contatnment Floa(s)and Chum(s). P co this Forth. Include information for every tank and dispenser at the facility. C' CertitlCatlen -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 correct and a Plot Plan showing the layout of monitoring mpment. For any equipment capable necessary e o veru attached a copy of the report Jctreck all that that this information is aPP1Y) �System set-up g gsuch reports,I have also Technician Name tint : P ❑Alarm hisWry report (Plint): Robert Barnhart Certification No.: 835969 Signature: Testing Company Name: Reliablelel Service Inc. License.No $3706 Testing Company Address: 521 Branding Iron Street, Oakdale CA 95361 Phone No.: '209) 845-658ti Date of Testing/Servicing: 101221�py Page 1 of 4 CN-036—I/4 www.unidomorg Rev.01/17/08