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Monitoring System Equipment erti�icio For Uve 13v All durisc/ie o"S lI'rllti" Pic Slalc of C'u!{Ji,rnicr .4whoritr Cited: Cholver 6.', Necdth and.Safety Code: C7talver 16. 1lirrsion 3. Title 23. CaliJi�rrtiu C ndc nJ'Rc+,rrlutirna.t I his form must be used to document testing and servicing of monitoring equipment. A separate certilication or report must he prepared for each monitorirtg system control panel by the technician who perforins 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 re_, elating UST s%stern within;Q days of test date. A. General Information Facility Name: Chev 99840 Bldg.No.: Site Address: 4344 Waterloo Rd City: Stockton, CA Lip; 95215-2306 Facility Contact Person: Contact Phone No.: (209)931-2186 Make/Model of Monitoring System, gate of Testing:"Servicing R. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank 11)• Tank ID ❑ In- I ank Gauging Probe Vlcxtel. ❑ in- I ank o+aueine,Probe. Mod& 77� ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. \1+n1cL' ❑ Pipins_sump,'french Sensor(s). Modcl. ❑ Piping Sump I Tench Sensor hl. \lode! ❑ I ill Sump Sensor(s). Model: ❑ fill sump Sensor oil. SLnIeL ❑ Wchanical Line Leak[)elector. Mod"L_ o_ 13mechanical[.me t eak I)etector %ludel V1 lectnauc I me Leak Doccwr. tiludel: ❑ I lectronic Linc I eak I mcetor Uodel' ❑ 'tank overfill'",liigh-Level Sensor. \[cele!: ❑ 'I ank Oterlill I li,-,h-I.eccl Sensor. Model: ❑ ()[her(*cify equipment type and model ill Section,L on Page 2I. [3 o)thcr l specilj cquipnient type auul nicxiel in SceOon I on I'a!_e.'.). Tank iD Tank iD• ❑ In- I"ank Gauging Probe. ModcL ❑ In- l ank 6augut;_Prove Model: ❑ Annular Space of Vault Sensor. Model: ❑ Annular Space or Vault Scnsor. Modcl: ❑ Piping sump 'frrnchSensor Is). \Iod l: ❑ Piping Sump\Trench Sensor(s). Modd: ❑ Lill Sump Sensor(s). \'ICKICI: ❑ Pill Sump Sensor(s)_ \1rdel ❑ \icchamcal Lure Leak octecu,r. \[.Kiel: 13 \mcchanical I nm Leak Docctur. Mod& [3Hectromc tine I cal,tmector. Model: ❑ Flectronic I.inc Icak WCOor. \[colo! ❑ Tank Overfill\High-Level Sensor. ".todel: Q 7 ank Overfill,.lii_h-Ecce(Sensor. \tad I: ❑ Other t specity equipment type and model in Section G on Page 2). [3Other t specify equipment type and model in Secaom I_on Dispenser lU Dispenser IU ❑ Dispenser C:oittainment Sensor(s)- Model ❑ Dispenser Containment Sensor(s). Model ❑ Shear Valve(s1. ❑ Shear\atte(s). ❑ I)i>pcnser Containment Moat(s)and Chain(s). ❑ Dispenser Containment Hoat is)and Chain 1si. Dispenser iU Dispenser ID• p Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor is). Model: ❑ Shear Valve(s). ❑ ShearValve(s). ❑ Dispenser Containment float ts)and Chain(s). ❑ Dispenser Containment float(st and Chain isi. Dispenser l Dispenser iD ❑ Di penscrt'ontdinment Sensor(si. Memel: ❑ Dispenser Containment Sensor isi. Model: ❑ Shear Vol-is), ❑ ShearVahcisi. ❑ I)i pester(oniainment float(s)and Chain(si. ❑ Dispenser Containment float(si and Chain is). It the facility contains more tanks or dispenses.copy this form.Include information for every tank and dispenser at the tacil[ty (.Certilicatipn- t certify that the equipment identified in this document a"as inspcctrdiccniced in accordance ccith the ntanit fact urer's guidelines. Attached to this Certification is information(e.g.manufactures'checklists)necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable or generating such retorts.t have also attached a copy of the: !check all that apple)= ❑ tiestem ort-up ®heist vision report I echnician Name(print): Bryan I-undien Signature: Mui'.CC11.3?.: 5'5ib®aq ICC#! RU>14dek-u-S'` License.No.: 485184 1 cstins;Company Name Sery Sta Sys ['hone No.: (408)971-2445 Date of Testing%Servicim I esting Company Address: 680 Quinn Ave.,San Jose CA 95112 , 1�U5