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MONITVRJNG SYSTEM CERTIFIC TION 1�Jse By All Jurisdictions Within the State of Calilomi../ Authority Cited:Chapter 6.7,Heath and Safety Code;Chapter 16,Division 3 Title 23,Califomia 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 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 ownedopemtor. The owner/operator must submit a copy of this forth to the fowl 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: 03/08/2005 Facility Contact Person: MGR-PAT Make/Model of Monitoring System:VEEDER-ROOT Work Order Number: 2234928 S.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced Tank ID: SUP TanklD: PLUS X In-Tank Gauging Probe. Model: MAGA X In-Tank Gauging Probe. Model: MAGA X Annular Space or Vault Sensor. Model: 794390407 Annular Spam or Vault Sensor. Model: 794390-407 X Piping Sumprrrench Sensor(s). Model: 794380-208 Piping Sump/Trench Sensor(s). Model: 794380-208 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 Tank Overrill/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: Tank ID: X In-Tank Gauging Probe. Model: MAG-1 In-Tank Gauging Probe. Model: X Annular Spam or Vault Sensor. Model: 794390407 Annular Spam or Vault Sensor. Model: X Piping Sump/rmnch Sensor(s). Model: 794380-208 Piping Sumprrrench 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: 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). Dispenser 1/2 Dispenser ID: 3/4 M Dispenser Containment Sensor(s) Model: 794380-208 Xj Dispenser Containment Sensor(s) Model: 794380-208 X Shear Valve(s). -Xi Shear Valve(s) Dispenser Containment Float(s)and Chain(s). 7Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5/6 Dispenser ID: 7/8 XJ Dispenser Containment Sensor(s) Model:794380-208 71 Dispenser Containment Senwr(s). Model:794380-208 X❑ Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: 9/10 Dispenser ID: 11/12 71 Dispenser Containment Sensor(s) Model:794380-208 X Dispenser Containment Senwr(s). Model:794380-208 FXJ Shear Valve(s). X Shear Velvets). E1Dispenser Containment Float(s)and Chain(s). Dispenser Containment Floats)and Chaints). 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 ❑Alarm history report Technician Name(print): HEATH MCEVER Signature: Certification No.: 3604 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: 03/08/2005 Page 1 of 3 Based on CA form dated 03/01 Monitoring System Certification