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Ma 1*18 11 11:50a Reliable Petroleu 2 -845-8953 p.2 MONITORING SYSTEM CERTIFICATION For Use By .411 Jurisdictions Within the State of California Authority Cited: Ch rpler 6.7. Health and Safety Code; Chapter 16, Division 3, Title 23, Coi ffornia Code of Regulations This form must be used to d4 ument testing and servicing of monitoring equipment. A separate certification or revort must be prepared for each monitoring system control j by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The ownerloperator mus"subr it a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Int Facility Name: Wilson Site Address: 437 N. VI Facility Contact Person: - Makel Model of Monitori B. Inventory of Eq Chevron Mehroke System: Veeder- Root TLS -350 Tested/Certified Bldg. No.: City: Stockton CA Zip: 95205 Contact Phone No.: (209) 942-2344 Date of TestingjServicing: 2(1512011 Tank ID: T1:87 Tank ID: T2:91 Z In -Tank Gauging Probe. Model: 847390-109 Z In -Tank Gauging Probe_ Model: 847390-109 ® Annular Space o- Vault Sonsc i Model: 794390-407 3 Annular Space or Vault Sensor. Model: 784390407 1 Z Piping Sump /Trench Senso ). Model: 794380-208 Z Piping Sump ! Trench Sensor(s). Model: 794380.208 Z Fill Sump Sensor(s). Model: 794380-208 Z Fill Sump Sensor(s). Model: 784380-208 Z Mechanical Line Leak Detect Model VMI 99LD-2000 ® Mechanical Line Leak Detector. Model: R.J. FX1V ❑ Electronic Line Leak Detecto Model: ❑ Electronic Line Leak Detector. Model: 4 ❑Tank Overfill !High -Level S sac Model: 01 ank Overfill ! High -Level Sensor. Model: ❑ Other (specify equipment typ 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 -yank Gauging Probe. Model: ❑ Annular Space or Vault Sensc Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump ! Trench Sensor ). Model: ❑ Piping Sump ! Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Linc Leak Detect r. Model: ❑ Mechanical Line Leak Detector. Model: I ❑ Electronic Line Leak Detecto Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overf II J High -Leve[ S or. Model: ❑ Tank Overfill ! High -Level Sensor. Model: ❑ Other (specify equipment typ 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: 3&4 ® Dispenser Containment Sens s). Model: 330212-001 ® Dispenser Containment Sensor(s), Model: 330212-001 ® Shear Valve(s). ® Shear Valve(s), El Dispenser Containment Float ) and Chain(s). ❑ Dispenser Containment Floats) and Chain(s). Dispenser ID: 5&6 Dispenser ID: 7&8 Z Dispenser Containment Sens( qs). Model: 330212-001 ® Dispenser Containment Senson(s). Model: 330212-001 10 Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float ;)and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser ContainmentSens (s). Model: [3 Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float ) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). *If the facility contains more C. Certification - i c guidelines. Attached correct and a Plot Pin attached a copy of the Technician Name (print) Certification No.: A301 Testing CoMpany Name: Testing Company Addre! or dispensers, copy this Corm- Include information for every tank and dispenser at the facility. ify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is bowing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also port; (check a[t that apply): ® System set-up ® Alarm history report 3uadalupe Sanchez Signature: License. No.: 883706 telial3le Petroleum Services Inc. Phone No.: (209) 845-8586 11930 Horseshoe Road, Oakdale CA 95361 Date of Testing/Servicing: 211512011 Page 1 of 3 - Rev (2/08)