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04/16/2004 10:59 1209365 43 TANKNOLOGY PAGE 06 ONIT G SYSTEM CE TI IC N For Use By All Jurisdictions Within the State of California Authority Cited;Chapter 6,7,Health acid Safety Code;Chapter 16,Division 3 Title 23,Ca/ifomie Code of Regulations This form must be used to document testing and servicing of monitoring equipment, If more then one monitoring system control panel Is Installed at the facility,a separate j; r ,pn-or report must ba RCBRa for each monkerino systam control Qenel by the technician who performs tho work. A copy of this form must be provided to the tank system owner/operator. The owner/operstor 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. CHEVRON#94275 City: STOCKTON CA Zip:85207 Site Address: 2905 W.BENJAMIN HOLT Contact Phone No; 478.5555 _ A 1-5 -- Date of Testing/$ervice; 03/29/2004 Facility Contact Person: MGR-BELINDA Make/Model of Monitoring System'TLS-350R Work Order Number: 2230345 B.Inventory of Equipment Tested/Certifled Check the appropriate boxes to indicate specific equipment inspected/serviced Tank ID; 5.87#3 Tank ID: X In-Yank Gauging Probe. Modol: MAG in-Tank Gauging Probe. Model: X Annular Space or Vault Sensor. Model: 407 Annular Space or Vault Sensor, Model: X Piping Sump/Trench$onw(s), Model: 208 piping Sump/Trench Sensor(s). Model: X Fill Sump S"or(a). Model; 208 — Fill Sump Sonsor(s). Modol: Mechanical line Leak Detector. Model: ❑ Mechanical Line Leak Detector, Model: i:lectronic Line Leak Detoctor, Model: Elocironic Line Leek Detector. Modoh _ Tank Overtpl/ttigh-Level Sensor. Model: Tank Overfill/High-Leval Sensor. Model: Other(specify equipment type and model in Section E on pago 2), Other(9pAcify equipment type and madel in Section E on page 2). an fD' Tank f In-Tank Gauging Probe. Model: in•Tink Gaugtng Probe. Model: Annular$pace or Vault Sensor. Model: Annular Space or Vault Sensor. Model: Piping$umpfrrench Senaor(s). Model; Piping Sump/Trench$onsor(s), Model: Fill Sump Sensor($). Model: Fill Sump Sensor(a). Model; Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector, Model; Eleetmnio Line Leak Detector, Model: Eloctronic Line Leak Detector. model: Tank OverfllilHigh-Level Sensor. Model: Tank OverfillMigh-Level sensor, Model: Other(specify equipment type and model in Section E on page 2). 71 Other e A p type page ) ( p.clty equipment a and model In Section E on a e 2. Ispenser . Dispenser I D:___ Dispenser Containment Sensor(s) Model: 7 Dispenser Containment Sensor(s) Model: Shear Valve(s), Shear Velve(s) Dispenser Containment Float($)and Chain(s). Dispenser Containment Flost(s)and Chain(s), Dispenser ID; Dispenser ID; Dispenser Containment Sensor(a) Model: Dlapenaer Containment Sensoga). Model. Shear Vafve(s), Shear valve(s). Dispenser Containment pIoat(s)and Chaln(s). Dlspensor Containment Float(s)and Chain(s). Dispenaer10; Dispenser ID: ❑ Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s). Model:_ ® Shear Valve(a). Ej Shnar vdive(s), Dlspensor Containment Float(s)and Chain(s). ❑ Dispenser Containment Flost(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 1 certify that the equipment identlfled In this document was inspected/serviced in accordance with the manufacturers'guidelines. Attached to this cerifflcation is information(e.g manufac(urers'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-upx❑Alarm history report Technician Name{print}; DOLiGLAS NARTY Signature; Certlflcatlon No.: 006-05-0253 License.No.,. Testing Company Na me:Tanknology Phone No.: 800 800-4633 Site Address: 8900 Shoal Creek,Bldg,200 Austin TX 78757 _Date of Testing/Servicing' 03/28/2004 btoitRRtoring System CertificationPage 1 of 3 Based on CA form dated 03/01