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Monitoring ste Equipment er 'fici For Use By All Jurisdictions Within The State of California Authority Cited:Chapter 6.7,Health and Safety Code;Chapter 16,Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A s,MatP certification or rgport must be pYP =d.for each monitoring,syg m control panel by the technician who performs the work. A copy of this form must be provided F.-ee= '�M?l to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST system within 30 days of test date. A. General Information Facility Name:Chevron Bldg.No.: Site Address: 1103 S.Main St City: Manteca,CA Zip: 95337-5743 Facility Contact Person: Manager Contact Phone No.: (209)825-0174 Make/Model of Monitoring System: WR TLS-350 Date of Testing/Servicing: 2/9/11 B. Inventory of Equipment Tested/Certified Check dee appropriate boxes to indicate specific equipment inspected/serviced: F[3FiIi 112;,01-Prem Tank ID• 02-Rngu -Tank Gauging Probe. Model: VR 947390-197 ❑ In-Tank Gauging Probe. Model: VR 8N -to7 nular Space or Vault Sensor. Model: M Annular space or Vault Sensor. Model: VR 794390-409 VR 794380-MB ping Sump\Trench Sensor(s). Model; ® Piping Sump\Trench Sensor{s). Model: Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ echanial Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: VR S00108 9494 C) Electronic Line Leak Detector. Model: [3 Tank Overfill\High-Level Sensor. Model: p Tank Overfill\High-Level Sensor. Model: [3 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 IDS-Regu Tank In- ❑ In-Tank Gauging Probe. Model: VR 947390.707 ❑ In-Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: VR 794390401 [3Annular Space or Vault Sensor. Model: ® Piping Sump\Trench Sensor(s). Madel: VR 794380-Z08 ❑ Piping Sump\Trench Sensor(a). 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: VR Series 8404 ❑ Electronic Line Leah 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). Dispenser ID• 01-02 Dispenser ID: 03.44 ® Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model: VR M Shear Valve(s). 0 Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID• ® Dispenser ID; 0708 Dispenser Containment Sensor(s). Model: M Dispenser Containment Sensor(s). Model: VR 0 Shear Valve(a). ® Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). rDispenserl Containment Float(s)and Chain(s). Disppenser ID• W10 D• 1142 M Dispenser Containment Sensor(s). Model: Containment Sensor(s). Model: VRShear Valve(s). e(s). Dispenser Containment Float(s)and Chain(s). 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 manufacturer's guidetlnes. Attached to this Certification is information(e.g.manufactures'checklists)necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attached a copy of the; (cheek all thatappry): ❑ System set-up ❑ Alarm history report Technician Name(print):Alex Bara)as Signattlre: C&I Mfg.Cert.#.: B35546 ICC# 5275949-UT License.No.: 485184 Testing Company Name: Service Station Systems Phone No.: (408)971-2 Testing Company Address: 680 Quinn Ave.,San Jose,CA 95112 Date of Testing/Servicing: 2/9/11