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r Monitoring System Equipment Certification 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 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 to the local agency regulating UST system within 30 days of test date. A. General Information Facility Name:Chevron Bldg.No.: City: Manteca,CA Zip: 95337-5743 Site Address: 1103 S.Main S4 Facility Contact Person: Manager Contact Phone No.: (209)825-0174 Make/Model of Monitoring System: V1R TLS-350 Date of Testing/Servicing: 2/9/11 J� B. Inventory of Equipment Tested/Certified Cheek tate appropriate boxes to indicate specific equipment inspected/serviced: Tank IQ.01-Prem Tank Int 02-Regu [3 In-Tank Gauging Probe. Model: VR84T390-107 E3 In-Tank Gauging Probe. Model: y�s47� 9 0 Annular Space or Vault Sensor. Model: vR 794390-409 f0 Annular Space or Vault Sensor. Model: 40 ® Piping Sump\Trench Sensor(s). Model: VR 790380.208 w Piping Sump\Trench Sensor(s). Model: VR 79+380-208 ❑ 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: VR Serks 8484 ❑ 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). Tank ID 03-Regu Tank IIL•- ❑ In-Tank Gauging Probe. Model: VR 017390-107 ❑ In-Tank Gauging Probe. Model: X Annular Space or Vault Sensor. Model: VR 7ai.790 409 ❑ Annular Space or Vault Sensor. Model: a Piping Sump\Trench Sensor(s). Model: VR 794380408 ❑ 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: VR series 8484 ❑ 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). Dispenser ID• 01.02 Dispenser ID- 0304 20 ® Dispenser Containment Sensor(s). Model: YR 7943 .208 ® Dispenser Containment Sensor(s). Model: VR 784380.208 Shear Valve(s). 0 Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID• O5,0e Dispenser ID- 07.08 ® Dispenser Containment Sensor(s). Model: VR 794380-208 g Dispenser Containment Sensor(s). Model: VR 794380-208 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID• 09-10 Dispenser I . 11-12 is Dispenser Containment Sensor(s). Model: VR 794380.208 a Dispenser Containment Sensor(s). Model:—VR 794380.200 ® 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 manufacturer's guidelines. Attached to this Certification is information(e g.manufactures'checklists)necessary to verify that this information is correct and a Plot Pian 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 any).' ❑ System set-up ❑ Alarm history report (print): : 3", 44- Technician Name(p )'Alex Barajas Signature Mfg.Cert.#.: B35546 ICC# 5275949-UT License.No.: 485184 Phone No. 408 971-2445 Testing Company Name: Service Station Systems __ �.� Testing Company Address: 680 Quinn Ave.,San Jose,CA 95112 Date of Testing/Servicing: 219/11