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06/06/2002 10:33 20936r--%&63 TAWNOLOGY PAGE 07 . r MnkmakW MONITORING SYSTEM CERTIFICATION For use Sy mairisdowne W01h fie State of CatNomia Aufhoftty Cited Chapter 8 7, Nealdl and Safety Cada; Chapter 16, Div)ai— 3 TWO 23, C&ftrnia Qode of Reyu►af 011s This form must bir Used io docun1,0111 fe9ting and servicing of monitoring equipment. If =to than one monitoring system control panel is installed at the fadllty, s eeperale cgd1WWorr*bo[ja)usIkj Io panel by the technician Who perform the work. A copy of this form must be provided to the tank em system aer/operstor, The owner/opnraT-W mU�t ',,jinn a copy of this form to the local "gamy regulating UST systems within 30 days of test date. A. General Information FacMity Name: CHE=VRON STATION #201383 Site Address: 1960 W. 11TH STREET Facility Contact Person: DEALER/MANAGER City: TRACY Confect Phone No: ;8,36-3181 Data of Testhfg/SOIVIOW . Make/Modal of Monitoring System: VR TLS -350 Work Order Number. 2222458 0. Inventory of Equipment TcetaViDertifled Check the anpropflate boxes to indicate spsdf(c equipment inspedeftervicled CA Tank ID: _REG ID: PLS X In -Tank Gauging Probe. WOO.847980.109 in -Tank Gauging Probe. N 1: 9473WI09 XAnnular Space or Vault SensorM0091 794M4WAnnular Spm or Vault Sensor. Modef: 784380.407-..._X Piping Sum/rrench Sensor(,u Morcel 794380208Pipi g $um pfrrench Sersor(s). Model: 794584-208FI® Sump Sensor(s). M4(W —FIB jTank Sump Sensor(s). Model: Mechanical Line Leak Delecinr. Wklel Mechanical Line Leak Detector. Model:E lectrormic Line LeU DetectorMorcel PLLDElectronic Line Leak Detector. MSI: PLLD Tank OverfltUHigh-Level Senxnr Mr&3 61SOTank OveA llgh•Level Sensor, Model; 61SO Other (specify equipment type-' ar,d rrm del in Section E on page 2Other (specilly equipment type and model it Sedion E On Page 2). Tank ID: F15114 ark D: X WTank Gauging Probe. model- 647M 109 In -Tank Gauging Probe. Model: X Annular Space or Vault Sensor Mork i 794390407 Annular Space or Vault Sensor. Model: X Piping Sump/rrench Sensori-,) Modwm. 794380208 Piping Sump/Trgnch Sonsor(s). Model: Fill Sum Sensor(s). Mods'i FIN Sump Sensor(s). Model: Mechanical Lire Leek Detector Morkar. Mechanical Line Leak Detector, Model: X Electronic Line Leak Detector MOW. PLLD Electronic Lite Leak Defector, Model: X Tank Ovet/11VF11gh•Levei Senvnr MadRl 61 SO Tank OvedliVHigh-Level Sensor, Model: Other (specify equipment type. ,end modol in Sedion E on page 2). Other (specify equipment type and model it Section E on page 2). spensw : 1/2 ispens9r D: 7/8 X Dispenser containment senvrr0l Model 794380-M - Dispenser Containment Sensors) Model: 794380208_ X Shear VaNe(s). Shear VaNe(s) Dispenser Containment Floal(s) and rh4m(s). Dispenser Containment FIM(s) and Ct�1(s). Dispenser ID; 314 pense ID: 9/10 X Dispenser Containment Sen!+ur( t) Mo•iel• 794380.208 Dispenser Containment Serstor(s). Model, 784380-2()8 X Shear Valve(s). Shear Vahe(s). Dispenser containment Floam(s) and ChWn(s). Dispenser Containment F (s) and Ch®im(s). jDisWeunser Dispenser ID: 5/6 �T ID: 11/12 X Dispenser Containment Sow"orl iii Mosel 79 4-2. Dispenser Containment Sensor(s). Model: 784300-208 X Smear Va rs(s). Shear VaNe(s). 13 Dispenser Containment Floatis) and Chain(-,). Dispenser Containment Floel(s) and Chai(s), It the facility .at:tains more tanks or dapansers, Wpy 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/servlced In mocmdance with the manufacturers' guidelines. Attached to this cortlflcation is information (e.g manufacturers' cheddists) necessary to verify that this Information is otmect. and a site Plan showing the layout of mnnitoring equipment For any et;)ulpmant capable of generating such reports, I have also attadsed a copy of the (Check all drat apply) System set up (aolt; Alarm history report PRINTED NAME: MICHAEL T LEVE:SQUE SIGNATURE: COMPANY: Tanknology PHONE NO: page 1 of 3 r �= ()344) ()004(393 -- BMW 0n CA form dated 03/01