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ONITORING SYSTEM CERTIFICATION se By All Jurisdictions Within the State of California Authority Cited:Chapter 6.7, ealth and Safety Code,Chapter 16,Division 3 Title 23,Ca ornia Code of Regulations This form must be used to document testing and servicing of monitoring equipment. lt more than one monitoring system control panel is installed at the facility,a separate certification or report must be prepared for each monitorina system control panel by the technician who performs the work. A copy of this form must be provided to the tank s em 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. eneral Information Facility Name: CHEVRON 201761 City: MANTECA CA Zip: 95337 Site Address: 1103 S.MAIN ST. Contact Phone No: 825-0174 Facility Contact Person: MANAGER Date of Testing/Service: 06/03/2002 Make/Model of Monitoring System: VEEDER ROOT TLS Work Order Number: 2222210 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced Tank ID: SUPER Tank ID: PLUS X In-Tank Gauging Probe. Model: 847390 X In-Tank Gauging Probe. Model: 847390 X Annular Space or Vault Sensor. Model: 794390-407 Annular Space or Vault Sensor. Model: 794390-407 X Piping Sump/Trench Sensor(s). Model: 794380-208 Piping Sump/rrench Sensor(s). Model: 794380-208 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 X Electronic Line Leak Detector. Model: PLLD 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). Tank ID: Tank ID: X In-Tank Gauging Probe. Model: 847390 In-Tank Gauging Probe. Model: X Annular Space or Vault Sensor. Model: 794390-407 Annular Space or Vault Sensor. Model: X Piping Sump/rrench Sensor(s). Model: 794380-208 Piping Sumpfrrench 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 Overfilt/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). ispenser : 1-2 Dispenser ID: 3-4 Dispenser Containment Sensor(s) Model:794380-208 X Dispenser Containment Sensor(s) Model:794380-208 Shear Valve(s). 7Shear Valve(s) ❑Dispenser Containment Float(s)and Chain(s). 7 Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5-6 Dispenser ID: 7-8 X� Dispenser Containment Sensor(s) Model:794380-208 71 Dispenser Containment Sensor(s). Model:794380-208 Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: 9-10 Dispenser ID: 11-12 Dispenser Containment Sensor(s) Model:794380-208 X Dispenser Containment Sensor(s). Model:794380-208 ❑ Shear Valve(s). 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-up report; ❑ Alarm history report 1771 PRINTED NAME. ANEIL CHAND SIGNATURE: 0 PANY: Tanknology PHONE NO: (800)800-4633 page 1 of 3 Based on CA form dated 03/01