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MONITORING SYSTEM CERTIFICATION F e By All Jurisdictions Within the State of California Authority Cited:Chapter 6.7,H and Safety Code;Chapter 16,Division 3 Title 23, Cal 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 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: USA#03696(CHEVRON BRAND NAME) City: LODI CA Zip:95242 Site Address: 2448 W KETTLEMAN LN Contact Phone No: 369-3124 @ LOWER SACRAMENTO RD Date of Testing/Service: 06/06/2005 Facility Contact Person: MGR-DAVE Make/Model of Monitoring System:TLS Work Order Number: 2236756 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate spec equipment inspected/serviced Tank ID: 1-91 Tank ID: 2-87 X In-Tank Gauging Probe. Model MAG X In-Tank Gauging Probe. Model_ MAG X Annular Space or Vault Sensor. Model 407 X1 Annular Space or Vault Sensor. Model: 407 X Piping Sump/Trench Sensor(s). Model 355 X Piping Sump/Trench Sensors) Model: 208 X Fill Sump Sensor(s)_ Model 355 Fill Sump Sensor(s) Model: 355 Mechanical Line Leak Detector. Model FX1 V X Mechanical Line Leak Detector Model FX1 V Electronic Line Leak Detector. Model 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). Tank ID: Tank ID: X In-Tank Gauging Probe Model: MAG In-Tank Gauging Probe. Model: X Annular Space or Vault Sensor Model 407 Annular Space or Vault Sensor Model: X Piping Sump/Trench Semor(s). Model 355 Piping SumprTrench Sernor(s) Model: _R1 Fill Sump Sensor(s). Model: 355 Fill Sump Sensor(s). Model. X Mechanical Line Leak Detector Model FX1 V Mechanical Line Leak Detector Model: Electronic Line Leak Detector Model: Electronic Line Leak Detector Model: Tank Overfill/High-Level Sensor. Model. Tank OverfilllHigh-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 FIDispenser Containment Sensor(s) Model Dispenser Containment Sensor(s) Model XD Shear Valve(s) —X-1 Shear Valve(s) X❑Dispenser Containment Float(s)and Chain(s)_ X Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5/6 Dispenser ID: 7/8 ❑ Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s). Model: X❑ Shear Valve(s) Shear Valve(s) X Dispenser Containment Float(s)and Chain(s) 11 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) 10 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 X❑Alarm history report Technician Name(print): JOEY MESA Signature: / Certification No.: 006-05-1532 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: 06/06/2005 Page 1 of 3 Based on CA form dated 03/01 Monitoring System Certification