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i7 -iOY MONITORING SYSTEM CERTIFICATION i se By All Jurisdictions Within the State of Califonrl Authority Cited:Chapter 6.7, HMIth and Safety Code;Chapter 16, Division 3 Title 23, California 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 or report must be oreoared for each monitonno system control oanal Dy 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 dale. A.General Information Facility Name: CHEVRON#98264 City: TRACY CA Zip:95376 Site Address: 3775 TRACY BLVD Contact Phone No:836-9422 1-205 Date of Testing/Service: 09/17/2002 Facility Contact Person: MGR-PAT Make/Model of Monitoring System: VR TLS 350 Work Order Number: 2223759 B.Inventory of Equipment 7estedlCertifled Check the appropriate boxes to indicate specific equipment inspected/serviced Tank ID: REGULAR Tank ID: PLUS X In-Tank Gauging Probe. Model: MAG 71 In-Tank Gauging Probe. Model: MAG X Annular Space or Vault Sensor. Model: VR 407 Annular Space or Vault Sensor. Model: VR 407 71 Piping Sump/Trench Sensor(s). Model: VR 208 Piping Sump/Trench Sensor(s). Model: VR 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: VR PLLD X Electronic Line Leak Detector. Model: VR PLLD Tank Overfill/High-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). Tank ID: TanklD: X In-Tank Gauging Probe. Model: MAG In-Tank Gauging Probe. Model: )( Annular Space or Vault Sensor. Madel: VR 407 Annular Space or Vault Sensor. Model: X Piping SumpRrench Sensor(s). Model: VR 208 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: VR PLLD Electronic Line Leak Detector. Model: Tank Overfill/High-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). Ispenser 1/2 Dispenser ID: 7/8 MDispenser Containment Sensor(s) Model:VR 208 X Dispenser Containment Sensor(s) Model:VR 208 X❑Shear Valve(s). X Shear Valve(s) 0 Dispenser Containment Float(s)and Chain(s). Dispenser Containment Floats)and Chain(s). Dispenser ID: 3/4 DispenserlD: 9/10 X❑ Dispenser Containment Sensor(s) Model:VR 208 Dispenser Containment Sensor(s). Model:VR 208 X❑ Shear Valve(s). Shear Valve(s). Dispenser Containment Floats)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5/6 Dispenser ID: 11/12 Dispenser Containment Sensor(s) Model:VR 208 X Dispenser Containment Sensor(s), Model:VR 208 �X Shear Valve(s). X Shear Valve(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): System set-up report; Alarm history report PRINTED NAME:KEVIN MATLOCK SIGNATURE: COMPANY: Tanknology PHONE NO: (800)800-4633 page 1 of 3 Based on CA form dated 03/01