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White and Blue - Chevron Office Ms -9783 (1-98) <br />Canary - Station Copy: File in Tank Section of Compliance Work Book word Electronic version <br />f <br />Station No. /° Date <br />Make Model Test Date Test Result Testing Company and Testor Comments <br />/ Repaired <br />__(mm/dd/yy) <br />Signature <br />_. (mm/dd/yy) <br />Tanks: _ <br />Tank Level Monitor (TLM) <br />Annular Space Monitorns 1 1 <br />Turbine Scamp Probe ` $I'r <br />Turbine <br />Sump Probe CES <br />Spill Containment Fill Boxes �1 .r )� a , <br />L*, �ck <br />51- I <br />I I <br />2L <br />Mechanical Overfill Prevention a -t <br />Remote OverfillVIA <br />Audible and Visual Alarm � � -R <br />Electronic Line'" <br />Pressure Monitor. <br />Mechanic Leak Detector --- <br />j <br />Dispenser Impact Valve -i 1 ASS <br />Dispenser Sump, Probe <br />x .� -(t <br />f , <br />SuA <br />Emergency Shut-off Switch F 1 )� <br />, <br />Return to M.L. Farrar/L1114, P.O. B ox 6004, San Ramon, CA 94583 <br />1. Meets 1998 Regulations ❑ Yes ❑ No 4. Test date result and date repaired (if any) must be entered or form will be returned. <br />2. Use comments - as needed. 5. Return to Chevron Office as you complete. <br />3. DO NOT SEND FORM IN <br />BLANK or "DO NOT KNOW" IN SPACES. � 6. All forms should be completed by due date Assigned: � ,,� <br />White and Blue - Chevron Office Ms -9783 (1-98) <br />Canary - Station Copy: File in Tank Section of Compliance Work Book word Electronic version <br />f <br />Station No. /° Date <br />Make Model Test Date Test Result Testing Company and Testor Comments <br />/ Repaired <br />__(mm/dd/yy) <br />Signature <br />_. (mm/dd/yy) <br />Tanks: _ <br />Tank Level Monitor (TLM) <br />Annular Space Monitorns 1 1 <br />Turbine Scamp Probe ` $I'r <br />Turbine <br />Sump Probe CES <br />Spill Containment Fill Boxes �1 .r )� a , <br />L*, �ck <br />51- I <br />I I <br />2L <br />Mechanical Overfill Prevention a -t <br />Remote OverfillVIA <br />Audible and Visual Alarm � � -R <br />Electronic Line'" <br />Pressure Monitor. <br />Mechanic Leak Detector --- <br />j <br />Dispenser Impact Valve -i 1 ASS <br />Dispenser Sump, Probe <br />x .� -(t <br />f , <br />SuA <br />Emergency Shut-off Switch F 1 )� <br />, <br />Return to M.L. Farrar/L1114, P.O. B ox 6004, San Ramon, CA 94583 <br />1. Meets 1998 Regulations ❑ Yes ❑ No 4. Test date result and date repaired (if any) must be entered or form will be returned. <br />2. Use comments - as needed. 5. Return to Chevron Office as you complete. <br />3. DO NOT SEND FORM IN <br />