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RECEIVED <br />MONITORING G SYSTE T TIOfN <br />For U -Te Au JurisdidlnrL' 5"&'n rite State Q� C; 1 or;,la <br />414 <br />Authurety Cited., CAaprer 6.?, fldalth arae Y Code; Chapter fel, Dilia. 3, Titfe 23, Cadifarnia (:n i <br />This form inu$L be uscd to document testing avid servicing of monitoring equipment f r <br />monittnute syslg ennunf®snel by the tcdmicials Mio performs the work. A copy of this form most be psovi <br />The ownerlopexator must submit a copy ofthis form to the local agoncy regulating UST systems within 36 days of lot da"DEPARTMENT <br />A. General Information <br />Facility Name. Hammer Lane Chevron_ <br />Bldg. No. <br />Site Address: 3304 W. Hammer Late <br />City: Stockton, Ca. Zip: $5619 <br />FaciUtyConw Person: Mike <br />Contact Phone No.: {209} 47$•8293 <br />Make/Model of Monitoring System: Veeder Root TLS -350 <br />Date of Testingt5orvicing. 612012014 <br />B. Inventory of Equipment Tested/Certified <br />. Ckh-ck th c agglUriate boxes to IofSg s 'eifrc jeuipm Gtrwdlicrvieo:d: <br />Tank ID: T1: 87 <br />Tank iD: T2: 91 <br />® In- tank Ciaug+ng Probc. Modct: <br />Q In-TnMk Gosiog Probc, Model. <br />0 Annular Spam or vault Seng. Model: 794390-42p(Split.Tarlo) <br />® Annular Space ar`vault Sensor. Model: 79439 : jM$W it -Tank) <br />® Piping Sump I Trend, Sensar(a). Model: 79438D-208 <br />® Piping Swap I Trmtdt Sensor(s). Model: 7943843-M <br />0 Fill Sump Serosogs). Model: <br />Q bill Same $e nsVr(s). Model: <br />® Meelumimt Lino Leak Dole=. Model: FE Petro STP -MLD <br />M&Amnicul Linc Leak Ocbxtor. Model: FE Petro STI2 Ai4LD <br />❑ Electronic Litre Leak Detector. Modcl- <br />❑ E)COWia Linc Lcak Detectu- Model: <br />0 'ra nk overfill I High -Level Sa:lsor. MndcL <br />Q'rank (hw ll / Hight -Levet Sensor, Model: <br />Q Other {spccitY cgniPment We and rrnrdcl in Soctien E all Page 2). <br />Q Depen' (specify cquipmat type and model in Section E on Page 2). <br />'rant[ tlx: T3: Diesel <br />Tank tin: <br />Q In -Tank GaiWag Probe, Model; <br />0In-TankCAuginisProbe. Model: <br />® Annularapflco or Vauk' Sensor. Model: 794390.420 <br />Annular apace or Vault $c nom, Model: <br />® Piping SwV I Tronch Sensor(s). Model: 794380-208 <br />0 Piping Sump I Trench, Sensrx(s). Mpdd: <br />❑ Fill Sump Sensw(s). Model: <br />❑ Fill Sump Sensor(%). Madel: <br />® Mechanical Line Leak Detector. Model; RJ FX1 DV <br />Q Medrardnal line t tak Detector Model: <br />Q Elecrrinic tine Leak Detector, Model: <br />❑ Electronic Line Leak Ddleuor. Mode:: <br />❑ Tank Overfill f High-Iz vel Sensor, Model'. <br />Q Tank Omfrll / Hligh•Levcl Sensor. Mo1dd: <br />Q Otter (specify cgnipment .ypc and model in Section E on Pup 2), <br />Q Otiter (streoify equipment type anti model in Section Eta: Pine 2). <br />(Dispenser 10. 4&2 <br />ser AD: 3&4 <br />❑ Disptanzn:r Gen anent Swssw{s). Mtodek <br />Q Dispenser Contdriment Sentex(s). MwW- <br />® Shear Vdve(s). <br />® Shear Valve(s). <br />® Nopo nscr Containment Float(s) and Chain(s). <br />® Dispenser Containmtent Fi 3) and Cbnin(s). <br />Dispenser IID: 5&6 <br />Dispenser tri: 7&8 <br />Q Dispenser Costalnment Sot uJlr(s). Mndel; <br />® ll4sPenser C.pntsinment Sensor(s). ModcC <br />® shear valvas)_ <br />Is Shear valve (s). <br />® Dispenser Containment Float(s) and Chain(s). <br />® Dispenser t ontaimncat Fkxo) and C haia(s). <br />Diapenser 1®: <br />1)" r AD: <br />Q Disperser Cwnainmeat 1kiwx(s). Model: <br />Q Disporm Connrinmcnt Screens). Modal: <br />Q Sheat Valve(s). <br />® Shear valve(s). <br />❑ Dispeaset Colainm ent Float(s) and Clunin(s). <br />Q Dispenser Containment Flon(s) and C haln(s). <br />elf the facility contains more tanks or diapcnscrs, copy this form. Include inronxialion for every tank til dispenser at the facility. <br />C. Certification - h certify that the equipment identified In this doeunteat was inspeglad/serviced In accordance with the manufacturers' <br />guidelines. Attached to this Certiitestien is information (e.g. manufacturers' lists) necessary to verity that this tmforrmatiun is <br />correct and o Plot Plan showing the iayerut of mosito ' mlpment. For any equipment callable of generating such repasts, E have also <br />attaebed a copy of the report, (chedr all rhar ap*)e Systems set-up ® Alarm history report <br />Technician Name (print): Guadalupe Sanchez Signatt,�;►-- �•,,m,�- <br />Certification No.: A30138 License. No.: 803700 <br />Testing Company Name: Reliable Petroleum Services inc. Phone No.: (209) 846-6686 <br />Tearing Company Addrr..sx; 1193U HoMeehoe Rd. Oakdale, Ca.95361 Date of Testin8/Servicing: 612012014 <br />Page 1 of 4 <br />Rev (7JD8) <br />Z,d £9699V960Z wn9I04edelgella2i e0£:90t,186Inr <br />