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MONITORING SYSTEM CERTIFICATION JUL 2 7 2016 For Use By All Jurisdictions Within the State of California Authority Cited:Chapter 6.7,Health and Safety Code;Chapter 16,Division 3,Title 23,California Code of Regulahahg ��. This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be prepared for each monitorin 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: CHEVRON County: SAN JOAQUIN Site Address: 444 MOSSDALE City: LATHRUP Facility Contact Person: PAL Contact Phone Make/Model of Monitoring System: TLS350 Date of Testing/Servicing: 6/14/2016 B. Inventory of Equipment Tested/Certified Tank ID 87 Tank 1D: 91 ®In-Tank Gauging Probe. Model: MAG ®In-Tank Gauging Probe. Model: MAG ®Annular Space or Vault Sensor. Model: 420 ®Annular Space or Vault Sensor. Model: 420 1 Piping Sump/Trench Sensor(s). Model: 208 ®Piping Sump/Trench Sensor(s). Model: 208 ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ®Mechanical Line Leak Detector. Madel: FYIV ®Mechanical Line Leak Detector. Model: LD2000 ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ®'rank Overfill/High-Level Sensor. Model: FLAPPER ®Tank Overfill/High-Level Sensor. Model FLAPPER ❑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: DSL Tank ID: ®In-Tank Gauging Probe. Model: MAG ❑In-Tank Gauging Probe. Model: ®Annular Space or Vault Sensor. Model: 420 ❑Annular Space or Vault Sensor. Model (�Piping Sump/Trench Sensor(s). Model: 208 ❑Piping Sump/Trench Sensor(,). Model: ❑ Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: E Mechanical Line Leak Detector, Model: LD2000 ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ®Tank Overfill/High-Level Sensor. Model: FLAPPER ❑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 ID: 1/2 Dispenser ID: 3/4 ❑Dispenser Containment Sensor(s). Model: 208 ®Dispenser Containment Sensor(s). Model: 208 ®Shear Valve(s). ®Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5/6 Dispenser ID. 7/8 ®Dispenser Containment Sensor(s). Model: 208 ®Dispenser Containment Sensor(s). Model: 208 ®Shear Valve(s), ®Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s)- ❑ Dispenser Containment Float(s)and Chain(s), Dispenser ID: 9110 Dispenser ID: 11/12 ®Dispenser Containment Sensor(s). Model: 208 ®Dispenser Containment Sensor(s). Model: 208 (�Shear Valve(s). Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Check the appropriate boxes to indicate specific equipmentinspected/serviced: 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 Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attached a copy of the report;(check all that apply): ® System set-up ®Al rm history report Technician Name(print): TIM BURJART Signature: Certification B44849 License No.: 433159 Testing Company Name: B.Z.Service Station Maintenance Phone No.: (916) 371-2380 Site 1041 Triangle Court West Sacramento,CA 95605 Date of Testing/Servicing: 6/14/2016 Monitoring Certification Test Report I of 4