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ONI NG SYSTEM CE TIFI TION use By All Jurisdictions Within the State of Californ Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3 Title 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 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 #201383 Site Address: 1960W. 11TH STREET City: TRACY Contact Phone No: 836-3181 @ CORRAL HOLLOW Date of Testing/Service: 02/03/2012 Facility Contact Person: HELEN - PERMIT: (N-2515-1-3) Make/Model of Monitoring System:TLS-350 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced Work Order Number: 2284768 CA Zip: 95376 Tank ID: 87 Tank ID: 89 X In -Tank Gauging Probe. Model: MAG 1 _91 In -Tank Gauging Probe. Model: MAG 1 X Annular Space or Vault Sensor. Model: V/R 409 7X Annular Space or Vault Sensor. Model: V/R 409 X Piping Sump/Trench Sensogs). Model: V/R 208 Piping Sump/Trench Senso4s). Model: V/R 208 X Fill Sump Sensogs). Model: V/R 208 Fill Sump Sensor(s). Model: V/R 208 Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: X Electronic Line Leak Detector. Model: V/R PLLD X Electronic Line Leak Detector. Model: V/R PLLD X Tank Overfill/High-Level Sensor. Model: FLAPPER Tank Overfill/High-Level Sensor. Model: FLAPPER Other (specify equipment type and model in Section E on page 2). Othereci s equipment type and model in Section E on page 2). (p fy Tank ID: 91 TankID: In -Tank Gauging Probe. Model: MAG 1 In -Tank Gauging Probe. Model: X Annular Space or Vault Sensor. Model: V/R 409 Annular Space or Vault Sensor. Model: X Piping Sump/Trench Sensogs). Model: V/R 208 7Piping Sump/Trench Sensor(s). Model: X Fill Sump Sensogs). Model: V/R 208 7Fill Sump Sensogs). Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: X Electronic Line Leak Detector. Model: V/R PLLD Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: FLAPPER lDispenserlD: 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 : 1/2 3/4 ® Dispenser Containment Sensor(s) Model: V/R 208 X Dispenser Containment Sensors) Model: V/R 208 X� Shear Valve(s). X Shear Valve(s) 0 Dispenser Containment Float(s) and Chain(s). 7 Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5/6 Dispenser ID: 7/8 ® Dispenser containment Sensor(s) Model: V/R 208 X Dispenser Containment Sensor(s). Model: V/R 208 ® Shear Valve(s). 71 Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: 9/10 DispenserlD: 11/12 X❑ Dispenser Containment Sensor(s) Model: V/R 208 X Dispenser Containment Sensors). Model: V/R 208 Shear Valve(s). X 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-upX1 Alarm history report i Technician Name (print): TIMOTHY COULTER Signature: Certification No.: B34132 License. No.: 743160 (Class 'A' General Enginering Contractor License) Testing Company Name: Tanknology Phone No.: (800) 800-4633 Site Address: 11000 N. MoPac Expressway, suite 500, Austin, TX 78759 Date of Testing/Servicing: 02/03/2012 Monitoring System Certification Page 1 of 3 Based on CA form dated 03/08