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d . 4MONITORING SYSTEM CERTIFICATION r Use By All Jurisdictions Within the State of Calif Authority Cited.Chapter 6.Walth and Safety Code,Chapter 16,Division 3 Title alifomia 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 tote local agency regulating UST systems within 30 days of test date. A.General 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: 09/07/2001 Make/Model of Monitoring System: TLS350 Work Order Number: 2218410 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced Tank ID: PUL 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: 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). U15peri5er 1U. Dispenser ❑ 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: Dispenser Containment Sensor(s). Model: ShearValve(s). ShearValve(s). Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser lD: nDispenser 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/seryiced 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: COMPANY: Tanknology PHONE NO: (800)800-4633 page 1 of 3 Based on CA form dated 03/01