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,MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of Calofmia Authority Cr hapter 6.7,Health and Safety Code;Chapter 16,Divisionak 23,California Code of Regulations This Form must be used to document testing and servicing of monitoring equipment. If more than one monitoring system control panel is insalled at the facility, a separate certification or report must be prepared for each monitring 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 o t is form tot the local agency regulating UST systems within 30 days of test date. Instructions are printed on the back page. A. General Information Facility Name: CHEVRON 208118 Site Address: 3355 E. HAMMER LANE City: STOCKTON CA Zip:95212 Contact Phone No: 964-0180 Facilty Contact Person: MARK Date of Testing/Service: 06/27/2001 Make/Model of Monitoring System:TLS 350 Word Order Number: 2217361 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicate specific equipment inspected/serviced Tank ID: SUP Tank ID: REG 71 In-Tank Gauging Probe. Model: 8473 In-Tank Gauging Probe. Model: 8473 Annular Space or Vault Sensor. Model: 409 Annular Space or Vault Sensor. Model: 409 Piping Sump/Trench Sensor(s). Model: 208 Piping Sump/Trench Sensor(s). Model: 208 Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: 8473 Electronic Line Leak Detector. Model: PLLD 71 Electronic Line Leak Detector. Model: PLLD 71 Tank Overfill/High-Level Sensor. Model: 8473 -59 Tank Overfill/High-Level Sensor. Model: 8473 71 Dispenser Containment Sensor(s) Model: 208 Dispenser Containment Sensor(s) Model: 208 71 ShearValve(s). Shear Valve(s), Dispenser Containment Float(s)and Chains(s). Dispenser Containment Float(s)and Chains(s). Other(specify equipment type and model in Section E on page 2). Other(specify equipment type and model In Section E on page 2). an Ian: In-Tank Gauging Probe. Model: D 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: Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s)and Chains(s). Dispenser Containment Float(s)and Chains(s). Other(specify equipment type and model in Section E on page 2). Other(specify equipment type and model in Section E on page 2). C. Certification 1 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 Site Plan showing the layout of monitoring equipment.For any equipment capable of generating such reports, 1 have also attached a copy of the(Check all that apply): System set-up report; ❑ Alarm history report F] PRINTED NAME: MATT SIGNATURE: wee COMPANY: Tanknology PHONE NO: (800)800-4633 page 1 of 3 Based on CA form dated 05/00