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MONARING SYSTEM CERTIF&TION 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 repolasooma arm monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the"-drVAMU The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: Wilson Way Chevron Site Address: 437 N. Wilson Way City: Facility Contact Person: Aman Mehroke Make/Model of Monitoring System: Veeder-Root TLS -350 Check the annronriate boxes to indicate snecitic eauinment insnected/serviced: r BMF6NMENMUiE4LTH Stockton, Ca. I Contact Phone No.: (209) 942-2344 Date of Testing/Servicing: 2/16/2012 Tank ID: T1: 87 Tank ID: T2: 91 • In -Tank Gauging Probe. Model: 847390-109 In -Tank Gauging Probe. Model: 847390-109 • Annular Space or Vault Sensor. Model: 794390.407 Annular Space or Vault Sensor. Model: 794390-407 • Piping Sump / Trench Sensor(s). Model: 794380-208 Piping Sump / Trench Sensor(s). Model: 794380-208 10 Fill Sump Sensor(s). Model: 794380-208 Fill Sump Sensor(s). Model: 794380-208 ® Mechanical Line Leak Detector. Model: VMI 99LD-2000 ® Mechanical Line Leak Detector. Model: R.J. FX1 V El 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). Tank ID: 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). Dispenser ID: 1&2 Dispenser ID: 34 Dispenser Containment Sensor(s). Model: 330212-001 Dispenser Containment Sensor(s). Model: 330212-001 ® Shear Valve(s). Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5&6 Dispenser ID: 7&8 Dispenser Containment Sensor(s). Model: 330212-001 Dispenser Containment Sensor(s). Model: 330212-001 Shear Valve(s). Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ 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 manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' 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 report; (check all that apply): System set-up Z Alar history report Technician Name (print): Guadalupe Sanchez Signator Certification No.: A30138 License. No.: 883706 Testing Company Name: Reliable Petroleum Services, Inc. Phone No.: (209) 845-8586 Testing Company Address: 11930 Horseshoe Rd. Oakdale, Ca. 95361 Date of Testing/Servicing: 2/16/2012 Page 1 of 4 Rev (2/08)