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MONITNG SYSTEM CERTIFI�TION se By All Jurisdictions Within the State of Ca/ifomi Authority Cited: Chapter 6.7, and Safety Code; Chapter 16, Division 3 Title 23, omia Code of Regulations This form 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 cert fceton or report must be Prepared for each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating DST systems within 30 days of test date. A. General Information Facility Name: CHEVRON 91452 (N-618) Site Address: 334 E. MAIN ST City: RIPON Contact Phone No: 599-2313 @ HWY 99 Date of Testing/Service: 01/24/2008 Facility Contact Person: DEALER - MOHINDER Make/Model of Monitoring System:TLS 350 Work Order Number: 2254326 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced CA Zip: 95366 Tank ID: 91 Tank ID: 89 In -Tank Gauging Probe. Model: In -Tank Gauging Probe. Model: X Annular Space or Vault Sensor. Model: 409 X Annular Space or Vault Sensor. Model: 409 Piping Sump/Trench Sensor(s). Model: 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: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Ovefill/High-Level Sensor. Model: Tank OvefilUHigh-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: Tank ID: In -Tank Gauging Probe. Model: In -Tank Gauging Probe. Model: X Annular Space or Vault Sensor. Model: 409 Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: 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: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank OverfillMigh-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 : 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). - 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). Dispenser ID: Dispenser ID: Dispenser Containment Senmr(s) Model: 7 Dispenser Containment Sensor(s). Model: 7 Shear Valve(s). ShearValve(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 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): M System set-up XD Alarm history report Technician Name (print): KRISTOPHER BELL Signature: Certification No.: 833809 License. No.: Testing Company Name:Tanknology Phone No.: — i 11 800-4633 Site Address: 8501 N. MoPac Expressway, suite 400, Austin, TX 78759 Date of Testing/Servicing: 01/24/2008 Page 1 of 3 Based on CA form dated 03/01 Monitoring System Certification