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ONITORING SYSTEM CERTIFICATION or Use By All Jurisdictions Within the Stat lofmia 6thority Cit apter 6.7, Health and Safety Code; ChaptellWivision 3 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 insetted at the facility, a separate certification or report must be prepared for each monitring 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. Instructions are printed on the back page. A. General Information Facility Name: CHEVRON STATION #201383 Site Address: 1960W. 11TH STREET Facilty Contact Person: DEALER/MANAGER Make/Model of Monitoring System: VEEDER ROOT B.Inventory of Equipment Tested/Certified City: TRACY Contact Phone No: 836-3181 Date of Testing/Service: 03/29/2001 Word Order Number: 2216071 Check the appropriate boxes to Indicate specific equipment inspected/serviced CA Zip: 95376 Tank ID: SUPER TanklD: PLUS 71 In -Tank Gauging Probe. Model: TLS In -Tank Gauging Probe. Model: 71 Annular Space or Vault Sensor. Model: TLS 71 Annular Space or Vault Sensor. Model: TLS Piping Sump/Trench Sensor(s). Model: TLS Piping Sump/Trench Sensor(s). Model: TLS 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: TLS PLLD Electronic Line Leak Detector. Model: TLS PLLD Tank Overfill/High-Level Sensor. Model: Tank Overfill/High-Level Sensor. Model: Dispenser Containment Sensor(s) Model: TLS Dispenser Containment Sensor(s) Model: TLS ShearValve(s). Shear Valve(s). Dispenser Containment Float(s) and Chains(s). Dispenser Containment Float(s) and Chains(s). 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 : REGULAR I an In -Tank Gauging Probe. Model: TLS 7 In -Tank Gauging Probe. Model: -XlAnnular Space or Vault Sensor. Model: TLS 7Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: TLS 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: TLS PLLD Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: Tank Overfill/High-Level Sensor. Model: Dispenser Containment Sensor(s). Model: TLS Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s) and Chains(s). Dispenser Containment Float(s) and Chains(s). Other(specify equipment type and model in Section E on page 2). Other(specify equipment type and model in Section E on page 2). C. Certification 1 certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturer's guidelines. Attached to this certification is informafion (e.g manufacturer's 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: ANEIL CHAND SIGNATURE: AU_Aa__P COMPANY: Tanknology PHONE NO: (800) 800-4633 page 1 of 3 Based on CA form dated 05/00