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02/19/2003 16:35 FAX 9258425660 CHEVRON PRODUCTS CO)IPANP 1A001 2-14-03: 8:00AN: :526 66t 7666 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code;Chapter 16,Division 3, nlle 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be prepared for each monitoring system control panel by the technician who performs the worst. A copy of this form must be provided to the tank system owner/operator. The owner/operator must submit a copy of this fora to the local agency regulating UST systems within 30 days of test date. '/ A. General InSo Facility B1dg.No.:r! Site Address: CiZip Facility Contact Perso /ICon�tac¢tPGho/neNo.: Make/Model of Monitoring System: 0f_J4W-R,,y= Z.CS --�qXK_2 Date of Testing/Servicing: -,l LL/,a3 B. Inventory of Equipment Tested/Certified Cheek the apgoirriste boxes to indicates eciricequipment ins edtservieed: Tank ID: 2�/ Tank ID: ✓ O In-Tank Gauging Probe, Model: O In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: yJ3 -i�0�� W Annular Space or Vault Sensor. Model: tJ .9 Piping Sump/Trench Sensor(a). Model:72y ZTrD _.2�4 9 APPiping Sump/Trench Sensor(s). Model: 3 O-2o ❑ Fill Sump Sensor(s). Model: l7 Fill Sump Sensor(s). Model: O Mechanical Line Leak Detector. Model: 17 Mechanical Line Leak Detector. Model: 10 Electronic Line Leak Detector. Model:g4/fl .8'D-e!a / .95-IlElectronie Lina Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: O Tank Overfill/High-Level Sensor. Model: ❑ Other(specify ui 9meat typo and mode in Section B on Pago 2). O Other(specify equipment a and model in Section E on Page 2 Tank ID: ✓ _ Tank IDt O In-Tank GaugingProb . Model:_ ❑ In-Tank Gauging Probe. Modes: ,Q°Annular Space or Vault Sensor. Model: f/3go-Yb9 ❑ Annular Space or Vault Sensor. Model: piping Sump/Trench Sensor(e). Model:4EVZfel ^.2.0 y El Piping Sump/Trench Sensor(s). Model: O Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: O Mechanical Line Lcak Detector. Model: ❑ Mechanical Line Leak Detector. Model: 5a Electronic Line Leak Detector. Model: O Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: O Tank Overfill/High-Level Sensor. Model: ❑ Other s ecifSquigLent DXo and model in Section E on Pago 2). ❑ Other s eci equipment a and model in Section E on Page 2). Dispenser ID: / Dispenser ID: �3z� ispenser Co teinraent Sensors}. Model: 3 - Dispenser Cc tainment Sensor(s). Modcl: 77x/5�" 2_a 9 O Shear Valve(s}. ❑ Shear Valve(s). ❑ Dispenser Containment F10090 and Chain(s). ❑ Dispenser Containment Floa a and Chain(s). Dispenser ID: Dispenser Dispenser ID: 7 Dispenser Cc taintnent Sensor(s). Model:21V?ko—z e 7 x7=Dispmser Con inment Sensor(s). Model: 75 r/:3Ji0^aa ? ❑ Shear Valve(s). O Shear Valve(s). ❑ Dispenser Containment bloats and Chaln s. g ❑ Dispenser Containment Floats and Chain(s). Dispenser ID:9�/a Dispenser ID: i//i z_ fbDispenser Containment Sensor(s). Model: 79t/3,f0 2-0' e8-Dispenser Con ainment Sensor(s). Model: �l.3YrD---Ze O Shear Valve(s). O Shear Valve(s). OD' ser Containment Float(s)and Chain(g., O Dispenser Containment Floats 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 -1 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 equipment For any equipment capable of generatl g such reports,I have also attached a copy of the re ort•{check a!1shpt apply): System set-up ,�A hip + o Technician Name(print): j� /LSP/w/n/ Signature: a Certification No.: _3 3e9 License.No.: p? Testing Company Name:��r�Gv,t-1C�.dA.✓ Phone NoJ 2S— Address: a ;ZZP—5Z 4�� ;� — ,(7�/�Li..':, Date of Testing/Servicing: Page 1 of3 03/01 Monitoring System Certification