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UAU SYSTEM CERT11*1T1110ECEMED F"r U�s ;, 4 11 Jurisdictions Within the State of Calybrnia Authority Cited, Chapter 6.7, Health and Safety Code, Chapter 16, Division 3, Title 23, Cal#rbrnia co This form must be used to document testing and servicing of in E.viry PC on The owner/operator must submit a co Tic WOK 7FcOPY oTthis form must be provided to tp~06E UN& A. General Information Py of this form to the local agency regulating UST systems within 30 days of test date. Facility Name: WILSON WAY CHEVRON Bldg. No.: Site Address:Wilson Way City: Stockton zip: 95206 Facility Contact Person: Aman Mehroke Contact Phone No.: Make/Model of Monitoring System: Veeder Root TLS -350 V. Inventory of Equipment Tested/CertifiDate ed of Testing/Servicing: 2M 8/2010 UN -036 T n k D T Tank ID: TI: Reglular R 9 Gaugingr ProbeP 0 . El In -Tank Gauging Probe. Model: g Tank 1D:. T2: Supreme Arm S Space ce 0 V u Vault 0 Annular Space or vault Sensor. Model: 407 * Piping Sump /Trench sensor(s). Model: 10-8-1 P PipingSump P in P n c 0 In -Tank Gauging Probe. ®Annular Space or Vault sensor, Model: 407 I S * Fill Sump Sensor(s). 0 P Sensor(s). s) Model: 208 SLine ®Piping SUMP /Trench Sensor(s). Model: 208 M Mechanical an L c Line ekD L Mechanical Line Leak Detector. Model: Electronic c n i E 1n) in 0 e Dgk 0 0 Electronic Line Leak Detector. ®Fill Sump Sc�so*), Model: 208 0 Mechanical Line Leak Detector. Model: FXIV Model: 0 0 an rfi I eves Tank Overfill / HiSh-Level Sensor. Model: e ----------- 0 Electronic, Line Leak Detector. Model: Other (specify quipm, 0 Other (specify equipment type and model in E on Page 2) MINIMUM" 0 Tank Overfill / High -Level Sensor. Model: -------------- ---- 0 Other (succiN equipment tvn,- and model in Section Tank ED: E on Page 2). 0 an Gauging Gauging Probe. g Probe 0 In -Ton n Model: 0 Annular 0 Annular Space or Vault Sensor. Space 0, Vault Tank ID: -Tan Gauging Probe. 0 In Model: Model: • Piping Sump Trench SensWs). Model: 0 Annular Space or Vault Sensor. Model: • Fill Sump Sensor(s). Model: 0 Piping Sump / Trench Sensor(s). Model: • Mechanical Line Leak Detector. Model: 13 Electronic Line LeakDetector. 0 Fill Sump Sensor(s). Model: --------- 0 Mechanical Line Leak Detector. Model: --------------- Model: 0 Tank Overfill / High -Level Sensor. Model- 0 Electronic Line Leak Detector. Model: ❑ Other (specify equipment type and model in'Section0 on Page �2)_ Tank Overfill / High -Level Sensor. Model: 0 other (specify equipment type and model in Section Tage2�). Dispenser ED: 1/2 Eon • Dispenser Containment 5) Model; Model: 00, Dispenser Dispenser ED: 3/4 7Sensor(s). • Shm Valve(s). E5 Dip, 0 Dispenser Containment sensor(s). Model: 001 t J!�j Dispenser COntainment Floats) and Chain(s). Show Valve(s). E3 Dispenser Containment Float(s) and Chain(s). Dispenser ED: 5/6 19 Dispenser Containment Sensor(s). Model- 0-01 Dispenser ED: 7/8 0 Shear Valve(s). ------------- Dispenser Containment sensor(s). Model: 001 0 Dispenser Containment Float(s) and Chain(s), Shear Valve(s). ------------- El Dispenser Containment Float(s) and Chain(s), Dispenser ID: Mm=WA=E= 0 Dispenser Containment sensor(s). Model: Dispenser ID: ------ 0 Shea, Valve(s). ---------- 0 Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Float(s) and Chain(s). 0 Shear Valve(s). --------- *If the facility contains more tanksor dispenseM ❑ copy this form. EJ Dispenser Containment Float(s) and Chain(s). Include information for every tank C. Cerfification -I r certify that the equipment Identified and dispenser at the facility. in this document was InsPected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (". manufacturers' cheddIsts) correct and a Plot Plan showing the layout of monitoring y to verify that this information is attached a COPY of the report; (check all that apply): ipment. For any equipment capable of generating Such reports I generaI have Mystem Technician Name (print): Robert also set-up R Alarm history report copt- a4-ooa�. kllSignature: BaMhart Certification No.: 835969 I or e Testing Company Name: Reliable Patrniza am Service Inc. License. No.: 883706 845 — Phone Nn.: f209) -858 Testing Company Address: 521 Branding Iron S!TPt Oakdale CA 95361 Date Of Testing/Servicin 9: 2118/2010 -1/4 Page 1 of 4 WWW.Uuidoes.org Rev. our/oll