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04/16/2004 10:59 , 1209365TANKNOLOGY PAGE 03 • IT 1 3S E iCE. TIFICA►T N c For Use By All Jurisdr'ctlons Within the State of Califomia Authority Cited;Chapter 6.7,Health and Safofy Code;Chapter 16,Division 3 Title 23,California Code of Regulations This form must be used to document testing and servicing of monitoring oquipmant. If more than one monitoring system control panel Is installed at the facility,a separate tgp er 32gd must bapamd-for each monitoring system Gantrol ganoLby the)tochnieian who performs the work, A copy of this form must be provided to the tank system owner/oparator. The ownerloperator must s<ttaTA a oopyctf'his#cunt 1,2 I s b•.scwt a9mvi re9Ws04 UIST vaWst?4,ftp;4f,ast daW A.General Information Facility Name: CHEVRON 0 94275 City: STOCKTON CA Zip:95207 Site Address: 2905 W.BENJAMIN HOLT Contact Phone No: 476-5555 I-5 Date of Testing/Service: 03/29/2004 Facility Contact Person: MGR-BELINDA Make/Model of Monitoring 5ysterrl:TLS-350R Work Order Number: 223D345 S.Inventory of Equipment Tested/Certified Check the appropriate voxes to indicate specific equipment Inspected/serviced Tank ID: 1-91 Tank ID: 2-89 X In-Tank Gauging Probe. Motlol; MAC ® In-Tank Gauging Probe. Model: MAG X Annular Space or Vault Sensor. Model: 407 ._ ® Annular Space or Vault Sensor. Model: 407 X Piping Sumptrrench Sensor(s), Model: 352 piping$ump/Tronch$onsor(s), Model; 352 X Fill Sump Sensor(s). Modol: Fill Sump Senaor(s). Model: 208 Mechanical Line Leak Detector. Model: Mochanieal Line Laak Detector. Model; Electronic Line Leak Detector. Model: PLLD X Electronic Line Leak Detector. Model: PLLD Tank Over ll/High-Level Sensor. Model: E1 Tank Overfill/Hlgh-Level Sensor. Model: Other(spacify oquipmont type and model In Section E on page 2). Other(Specify equipment type and model In Section E on page 2). Tank Tank ID: X InTank Gauging Probe. Model: MAG in-Tank Gauging Probe. Model: MAG X Annular Space or vauit Sensor, Model: 407 Annular Space or vault Sensor. Model: 407 )( Piping SumplTrench Sonsor(s). Model: 352 Piping Sumpfrrench Sensor(s). model: 352 X Fill Sump Sensor(s). Model: 208 Fill Sump Sensogs), Model: 209 Mechanical Line Leak Doloetor, Model; r7 Mechanical Line Leak Detector. Model: X Electronic Line Leak Detector- Model pLLD Electronic Line Leak Detector. Model: Tank Ovor illftph-Level Sensor. Model: Tank OverflttlHlgh.Level sensor, MedM: Other(specify equipment type and model in Sectlon E on page 2). r7 Other(specify equipment type and model In Section E on page 2). Dispenser Dispenser ID; 314 XeX Dispenser Containment$ensor(s) Modol:208 ® Dispenser Contslnment Sensors) Model:208 Shear Valve(s). ® Sheer Valves) Dispenser Contninmant Float(s)and Chaln(s). DISponsnr Containment Float(s)rind Choln(s), Dispenser ID: 5/6 Dispenser ID: 718 X Drsponser containment Sensors) Model;208 ® Dlspenser Containment Senaor(s). Model:208 ® Shear Velve(s). ® Shear Valve(s). Dlapenser Containment Floats)and Chaln(s). Dispenser Containment Floats)and Chaln(a). Dispenser ID; 9110 Dispenser ID: 11/12 X 4isponsor Containment Sensors) Modal:208 X Dispenser Containment$ensor(s), ModeC 208 X Shear Valve(s). X Shear Velve(e). Dispenser Containment Ftost(g)and Chlin(s), PIspenser Containment Floats)and Chaln(a). *If the facility contains more tanks or dispensers,Copy this form.Include Information for every tank and dispenser at the facility. C. Certification certify that the equipment identified in thls 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); DOUGLAS WARTY Signature; (i Certificatlon No.: 006-05-0253 license.No.: Teeming Company Name:Tanknology Phone No.: (800)800.4633 Site Address: 89M Shoal Creek,Bldg,200 Austin,TX 78757 Date of Testing/Servicing: 03/29/2004 Monitoring System CertificationPage 1 of 3 Based on CA form dated 03101