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d " n MONITORING SYSTEM CERTIFICATION Use By All Jurisdictions Within the State of Calif Authority Cited., Chapter 6.70Ith and Safety Code; Chapter 96, Division 3 Title *2alifornia 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 tis orm to t e 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: TLS350 B. Inventory of Equipment Tested/Certified City: TRACY Contact Phone No: 836-3181 Date of Testing/Service: 09/11/2001 Work Order Number: 2218409 Check the appropriate boxes to indicate specific equipment inspected/serviced CA Zip: 95376 Tank ID: RUL 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: PLLD 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). Other (specify equipment type and model in Section E on page 2). an an 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). Other (specify equipment type and model in Section E on page 2). U1bfjt!f1bU[ 1U. ispenser Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s) Model: ❑ Shear Valve(s). ShearValve(s) ❑ Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). DispenserDispenser . ❑ Dispenser Containment sensor(s) Model: 7 Dispenser Containment Sensor(s). Model: FjShearValve(s). 7 ShearValve(s). Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser lD: ❑ Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s). Model: ❑ ShearValve(s). ShearValve(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:DAVID MATHIE SIGNATURE: a 4f440kZ:L COMPANY: Tanknology PHONE NO: (800) 800-4633 page 1 of 3 Based on CA form dated 03/01