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d"- ONITORING SYSTEM CERTIFICATION 9° For Use By All Jurisdictions Within the State of Calofmia Authority Ci hapter 6.7,Health and Safety Code;Chapter 16,Division 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 insalled 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 o t is form tot a local agency regulating UST systems within 30 days of test date. Instructions are printed on the back page. A. General Information Facility Name: CHEVRON 201761 Site Address: 1103 S. MAIN ST. City: MANTECA CA Zip:95337 Contact Phone No: 825-0174 Facilty Contact Person: MANAGER Date of Testing/Service: 06/11/2001 Make/Model of Monitoring System:TLS 350 Word Order Number: 2216986 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicate specific equipment inspected/serviced TanklD: Sup TanklD: PLUS 71 In-Tank Gauging Probe. Model: 8473 71 In-Tank Gauging Probe. Model: 8473 71 Annular Space or Vault Sensor. Model: 409 71 Annular Space or Vault Sensor. Model: 409 71 Piping Sump/Trench Sensor(s). Model: 208 Piping Sump/Trench Sensor(s). Model: 208 Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: 39 Electronic Line Leak Detector. Model: PLLD 71 Electronic Line Leak Detector. Model: PLLD 71 Tank Overfill/High-Level Sensor. Model: 8473 71 Tank Overfill/High-Level Sensor. Model: 71 Dispenser Containment Sensor(s) Model: 208 Dispenser Containment Sensor(s) Model: 208 71 Shear Valve(s). 71 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 : REG an . In-Tank Gauging Probe. Model: 8473 7 In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 4U9 Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: 208 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: PLLD Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: 8473 Tank Overfill/High-Level Sensor. Model: Dispenser Containment Sensor(s). Model: 208 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 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, /have also attached a copy of the(Check all that apply): System set-up report; F—] Alarm history report _-1461Z PRINTED NAME: MATT SIGNATURE: A�Illa COMPANY: Tanknology PHONE NO: (800)800-4633 page 1 of 3 Based on CA form dated 05/00