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MONITORING SYSTEM CERTIFIC AXION lse By All Jurisdictions Within the State of Ca//fom. Authority Cited:Chapter 6.7,h"Ifth and Safety Code;Chapter 16,Division 3 Title 23,L'�ifomia 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 certification report must be prepared for each monitorinq 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 UST systems within 30 days of test date. A.General Information Facility Name: CHEVRON#98264 City: TRACY CA Zip:95376 Site Address: 3775 TRACY BLVD Contact Phone No: 836-9422 Date of Testing/Service: 03/20/2006 Facility Contact Person: MGR-PAT Make/Model of Monitoring System:VR-TLS350 Work Order Number: 2240382 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced Tank ID: 1 Tank ID: 2 X In-Tank Gauging Probe. Model: MAG X In-Tank Gauging Probe. Model: MAG X Annular Space or Vault Sensor. Model: 409 Annular Space or Vault Sensor. Model: 409 X Piping SumprTrench Sensor(s). Model: 208 Piping SumprTrench 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:l Electronic Line Leak Detector. Model: PLLD Tank Overfill/High-Level Sensor. Model: EXT.ANNUNCIATOR X Tank Ovefill/High-Level Sensor. Model: EXT.ANNUNCIATOR Other(specify equipment type and model in Section E on page 2). Other(specify equipment type and model in Section E on page 2). TanklD: 3 TanklD: X1 In-Tank Gauging Probe. Model: MAG In-Tank Gauging Probe. Model: )( Annular Space or Vault Sensor. Model: 409 Annular Space or Vault Sensor. Model: X Piping Sumprrrench Sensor(s). Model: 206 Piping SumprTrench 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 Electronic Line Leak Detector. Model: X Tank Overfill/High-Level Sensor Model: EXT.ANNUNCIATOR 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 1/2 Dispenser ID: 3/4 X❑Dispenser Containment Sensor(s) Model. 208 X Dispenser Containment Sensor(s) Model: 208 FX Shear Valve(s). -X-1 Shear Valve(s) ❑Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5/6 Dispenser ID: 7/8 QDispenser Containment Sensor(s) Model:208 Dispenser Containment Sensor(s). Model 208 rX Shear Valve(s). 71 Shear Valve(s). Dispenser Containment Float(s)and Chain(s). Dispenser Containment Floats)and Chain(s). Dispenser ID: 9/10 DispenserlD: 11/12 Dispenser Containment Sensor(s) Model: 208 X Dispenser Containment Sensor(s). Model:208 Shear Valve(s). X Shear Valve(s). Dispenser Containment Floats)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): System set-up X❑Alarm history report Technician Name(print): KELVIN CRUZ Signature: Certification No.: 006-05-1503 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: 03/20/2006 Monitoring System Certification Page 1 of 3 Based on CA form dated 03/01