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�IP MONITORING SYSTEM CERTIFICATION or Use By All Jurisdictions Within the State of Cal" Authority Cited. Chapter. ealth and Safety Code; Chapter 16, Division 3 TitAWCalifornia 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 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 STATION #201383 Site Address: 1960 W. 11TH STREET Facility Contact Person: DEALER/MANAGER Make/Model of Monitoring System: VR TLS -350 B. Inventory of Equipment Tested/Certified City: TRACY CA Zip: 95376 Contact Phone No: 836-3181 Date of Testing/Service: 06/04/2002 Work Order Number: 2222458 Check the appropriate boxes to indicate specific equipment inspected/serviced Tank ID: REG Tank ID: PLS In -Tank Gauging Probe. Model: 847380-109 E In -Tank Gauging Probe. Model: 847380-109 71 Annular Space or Vault Sensor. Model: 794390-407 X Annular Space or Vault Sensor. Model: 794390-407 Piping Sump/Trench Sensor(s). Model: 794380-208 X794380-208 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: PLLD X Electronic Line Leak Detector. Model: PLLD Tank Overfill/Nigh-Level Sensor. Model: 61 SO X Tank Overfill/High-Level Sensor. Model: 61 SO Other (specify equipment type and model in Section E on page 2). Other (specify equipment type and model in Section E on page 2). an an 71 In -Tank Gauging Probe. Model: 847380-109 In -Tank Gauging Probe. Model: 71 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: PLLD Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: g 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 ILT 1/2 rspenser ® Dispenser Containment Sensor(s) Model: 794380-208 Dispenser Containment Sensor(s) Model: 794380-208 ® Shear Valve(s). Shear Valve(s) Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser ispenser ® Dispenser Containment Sensor(s) Model: 794380-208 Dispenser Containment Sensor(s). Model: 794380-208 ® Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5/6 DispenseriD: 11/12 ® Dispenser Containment Sensor(s) Model: 794380-208 71Dispenser Containment Sensor(s). Model: 794380-208 ® Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser 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): System set-up report; ® Alarm history report PRINTED NAME:MICHAEL T LEVESQUE SIGNATURE: COMPANY: Tanknology PHONE NO: (800) 800-4633 page 1 of 3 Based on CA form dated 03/01