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MonitoringSystem Equipment ertificati ion For Use By All Jurisdictions Within The State of California Authority Cited.-Chapter 67,Health and Safety Code;Chapter 16,Division 3, Title 23„ �a1a}� zode ofReguCalrrsDe,'This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must prenared for each'tnonitorina 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 forin to the local jzc rjg (atLhg UST system within 30 days of test date. A. General Information -t.1 Facility Name:Chevron Site Address: 1103 S, Main St City: Manteca, CA Zip: 95337-5743 .Facility Contact Person: Manager Contact phone No.: (209}825-017.4 Make/Model of Monitoring System: V/R TLS-350 Date of Testing/Servicing: 1/19/12 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspeetedlserviced•, Tank ID-01-Prem Tank ID• 02-Regu 0 In-Tank Gauging Probe, Model: VR 847380-107 [1 in-Tank Gauging Probe. Model: VR 847390-107 0 Annular Space or Vault Sensor. Model: VR 794390:.408 C _Annular Space or Vault Sensor. Model: VR794390.409 09 Piping Sump t Trench Sensor(s): Model: VR 704380-20e IN Piping Sump\trench Sensor(s), Model: VR 794380-208 n Pill Sump Sensor(s), Model: 0 Fill Sump Sensor(s). Model: Mechanical Linc Leak Detector. Model: p Mechanical Line Leak Detector. Model: N Electronic Line Leak Detector. Modell VR Series 8484 1] Electronic Zine Leak Detector. Model'. 0 Tank Overfill t High-Level Sensor, Model: 0 Tank Overfill l High-Level Sensor. Model: C7 Other(specify equipment type and model in Section it on Page 2). C1 Other(specify equipmenttype and model in Section E on Page 2). Tank ID-,03-Rsgu Tank ID: 0 In-TankGauging Probe. Model: VR 847300=07 [1 In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: VR 784390.408 0 Annular Space or Vault Sensor. Model: Piping Sump l Trench Sensor(s). Model: VR 794`380-208 n Piping Sump'\Trench Sensor(s). Model: 0 Fill Sump Sensor(s). Model: 0 Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: 0 Mechanical tine Leak Detector, Madel: CA Electronic Line Leak Detector. Model; VR Series 848`4 D Electronic Line Leak Detector. Model: 0 Tank Overfill\High-Level Sensor. Model: 0 Tank Overfill\High-Level Sensor. Model: 0 Other(specify equipment type and model in Section E on;Page 2). n Other('specify equipment type and model in Section E on Page 2). Dispenser IDL 1 02 Dispenser ID: 03-04 CC Dispenser Containment Sensor(s). Model VR 784380=208 N :Dispenser Containment Sensor(s), Model: VR 794380-208 Shear Valve(s). 0 Shear Valve(s). Q Dispenser Containment Float_(s)and Chain(s); C7 Dispenser Containment Float(s)and Chain(s). Dispenser ID 05-os Dispenser I - 07-19 Ig Dispenser Containment Sensor(s). Model: VR 794380.208 Dispenser Containment Sensor(s). Model: VR 794380-208 9 Shear Valve(s). Shear Valve(s). 0 Dispenser Containment Float(s)and Chain(s). 0 Dispenser Containment Float(s)and Chain(s). 10 Dispenser ID. 09- 11-12 P Dispenser IDL 0 Dispenser Containment Sensor(s). .Model: VR 794380-200 0 Dispenser Containment Sensor(s). Model: VR 794380•208 91 Shear Vase(s). C9 Shear Valve(s). I] Dispenser Contaijument Float(s)and Chain'(s). 0 Dispenser Containment Floats)and Chain(s). *If the facility contains more tanks or dispensers,copy this form.Include information for every tank and dispenser atthe facility C.Certification- I 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.manufactures'checklists)necessary to verify that this information is correct and it Plot 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): Eg System set-up 51 Alarm history report Technician Name(print : Randy Wilkerson Signature: Mfg.Cert;#.: A32404 ICC# 5258560-UT license,No.: 485184 Testing Company Name: Service Station Systems Phone No.: (408)971-2445 Testing Company Address: 680 Quinn Ave., San Jose, CA 95112 Date of"l esting/Servicing: 1119112