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MONITNG SYSTEM CERTIFITION se By All Jurisdictions Within the State of Califomi Authority Cited: Chapter 6.7, and Safety Code; Chapter 16, Division 3 Title 23, omia Code of Regulations This forth 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 monitodno system control panel by the technician who performs the work. A copy of this form must be provided to the tank system ownedoperator. The owner/operator must submit a copy of this forth to the local agency regulating UST systems within 30 days of test date. A General Information Facility Name: CHEVRON 91452 (N-618) Site Address: 334 E. MAIN ST 0o HWY 99 Facility Contact Person: DEALER- MOHINDER City: RIPON Contact Phone No: 599-2313 Date of Testing/Service: 01/08/2008 Make/Model of Monitoring System:TLS 350 Work Order Number: 2253817 IS. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced CA Zip: 95366 Tank ID: 1-91 Tank ID: 2-89 _R1 In -Tank Gauging Probe. Model: MAG -1 X In -Tank Gauging Probe. Model: MAGA X Annular Space or Vault Sensor. Model: 409 Annular Space or Vault Sensor. Model: 409 71 Piping Sump/Trench Sensor(s). Model: 208 Piping Sump/trench Sensor(s). Model: 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: PLLD X Electronic Line Leak Detector. Model: PLLD X Tank Overfill/High-Level Sensor. Model: E/A Tank Overfill/High-Level Sensor. Model: E/A 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: Tank ID: 71 In -Tank Gauging Probe. Model: MAGA In -Tank Gauging Probe. Model: X Annular Space or Vault Sensor. Model: 409 Annular Space or Vault Sensor. Model: X Piping Sump/Trench Sensor(s). Model: 208 Piping SumpfTrench Sensor(s). Model: Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: X Electronic Line Leak Detector. Model: PLLD Electronicline Leak Detector. Model - Tank Overfill/High-Level Sensor, Model: E/A Tank Overfill/High-Level Sensor. Model: Other (specify equipment type and model in Section E on page 2). Others ( pacify equipment type and model in Section E on page 2). Dispenser 1/2 Dispenser ID: 3/4 M Dispenser Containment Sensors) Model:208 _Xj Dispenser Containment Sensor(s) Model: 208 IFX1I Shear Valve(s). X Shear Valve(s) ❑ Dispenser Containment Float(s) and Chain(s). -- Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5/6 DispenserlD: 7/8 x—]Dispenser Containment Sensor(s) Model:208 __Xj Dispenser Containment Sensor(s). MWa1:208 XJ Shear Valve(s). 71 Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser Containment Floats) and Cham(s). Dispenser ID: Dispenser ID: Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). Shear Valve(s). to Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). If the facility contains more tanks or dispensers, copy this forth. 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): ❑X System set-up X❑ Alarm history report Technician Name (print): HEATH MCEVER Certification No.: A27562 Signature: License. No.: Testing Company Name:Tanknology Phone No.: (800) 800-4633 Site Address: 8501 N. MoPac Expressway, suite 400, Austin, TX 78759 Date of Testing/Servicing: 01/08/2008 Monitoring System Certification Page 1 of 3 Based on CA form dated 03/01