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USAQUIPMENT MONITORING LA Facility Number: Chevron Station# Month/Year Equipment: VEEDER-ROOT TLS -350 Date Equipment Operational? Alarm Status O.K.? Comments Initials 01 Yes ❑ No ❑ Yes ❑ No ❑ 02 Yes ❑ No ❑ Yes ❑ No ❑ 03 Yes ❑ No ❑ Yes ❑ No ❑ 04 Yes ❑ No ❑ Yes ❑ No ❑ 05 Yes ❑ No ❑ Yes ❑ No ❑ 06 Yes ❑ No ❑ Yes ❑ No ❑ 07 Yes ❑ No ❑ Yes ❑ No ❑ 08 Yes ❑ No ❑ Yes ❑ No ❑ 09 Yes ❑ No ❑ Yes ❑ No ❑ 10 Yes ❑ No ❑ Yes ❑ No ❑ 11 Yes ❑ No ❑ Yes ❑ No ❑ 12 Yes ❑ No ❑ Yes ❑ No ❑ 13 Yes ❑ No ❑ Yes ❑ No ❑ 14 Yes ❑ No ❑ Yes ❑ No ❑ 15 Yes ❑ No ❑ Yes ❑ No ❑ 16 Yes ❑ No ❑ Yes ❑ No ❑ 17 Yes ❑ No ❑ Yes ❑ No ❑ 18 Yes ❑ No ❑ Yes ❑ No ❑ 19 Yes ❑ No ❑ Yes ❑ No ❑ 20 Yes ❑ No ❑ Yes ❑ No ❑ 21 Yes ❑ No ❑ Yes ❑ No ❑ 22 Yes ❑ No ❑ Yes ❑ No ❑ 23 Yes ❑ No ❑ Yes ❑ No ❑ 24 Yes ❑ No ❑ Yes ❑ No ❑ 25 Yes ❑ No ❑ Yes ❑ No ❑ 26 Yes ❑ No ❑ Yes ❑ No ❑ 27 Yes ❑ No ❑ Yes ❑ No ❑ 28 Yes ❑ No ❑ Yes ❑ No ❑ 29 Yes ❑ No ❑ Yes ❑ No ❑ 30 Yes ❑ No ❑ Yes ❑ No ❑ 31 Yes ❑ No ❑ Yes ❑ No ❑ on In the case of alarms, (audible alerts, warning and alarm system lights), system failure, tear off the Alarm Condition Report printout from your monitoring system and document the alarm condition under the appropriate category listed above. Using the Suspected Leak Activity Log, track your activities until "All Functions Normal" is displayed on the monitoring system console. Retain all alarm condition, test reports and repair work orders related to each alarm. O File the completed log with the UST Inventory Reconciliation Logs in the "Underground Storage Tank" Section of your station's Retail Facility Compliance Workbook Chevron Review (Name/Signature) Date: