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ONIT NG SYSTEM CERTIFIC ON FO 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 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 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 regulating UST systems within 30 days of test date. A.General Information Facility Name: CHEVRON#99840 City: STOCKTON CA Zip:95215 Site Address: 4344 WATERLOO RD Contact Phone No: 931-2186 @ 99 Date of Testing/Service: 02/20/2009 Facility Contact Person: MANAGER Make/Model of Monitoring System:TLS-350 Work Order Number: 2263813 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced Tank ID: 91 Tank ID: 87 In-Tank Gauging Probe. Model: ElIn-Tank Gauging Probe. Model: X Annular Space or Vault Sensor. Model: 409J FX Annular Space or Vault Sensor. Model: 409 X Piping Sumprrrench Sensor(s). Model: 352 Piping Sumprrrench Sensor(s). Model: 352 Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: �( Electronic Line Leak Detector. Model: VEEDERROOT X Electronic Line Leak Detector. Model: VEEDERROOT XTank 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: Tank ID: in-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: 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). 7 Other(specify equipment type and model in Section E on page 2). Dispenser : 1/2 Dispenser ID: 3/4 ®Dispenser Containment Sensor(s) Model:208 X Dispenser Containment Sensors) Model:208 X❑Shear Valve(s). X Shear Valve(s) E]Dispenser Containment Float(s)and Chain(s). 7 Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5/6 Dispenser ID: 7/8 0 Dispenser containment Sensor(s) Model:208 X Dispenser Containment Sensor(s). Model:208 X❑ Shear Valve(s). ® Shear Valve(s). 11 Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: 9/10 Dispenser ID: 11/12 RI Dispenser Containment Sensors) Model:208 X I Dispenser Containment Sensors). Model:208 X❑ Shear Valve(s). X Shear Valve(s). 10 Dispenser Containment Float(s)and Chain(s). 0Dispenser 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): �X System set-up X❑Alarm history report Technician Name(print): BRIAN MCPHEELY Signature: Certification No.: B36745 License.No.: 743160(Class'A'General Enginering Contractor License) Testing Company Name:Tanknology Phone No.: (800)800-4633 Site Address: 8501 N.MoPac Expressway,suite 400,Austin,TX 78759 Date of Testing/Servicing: 02/20/2009 Monitoring System Certification Page 1 of 3 Based on CA form dated 03/01