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07/23/2013 09:36 (209) 465-4988 MaryAnn Henderson Page 2/5 OPRO G SYSTEM CERTIFICATION 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 gM=te certification or report must be prepared for each Monitoring 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 of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: CHEVRON Bldg. No.: Site Address: 3304 HAMMER LANE City: STOCKTON Zip: Facility Contact Person: MGR Contact Phone No.: S ) Make/Model of Monitoring System: TLS 350 Date of Testing/Servicing: 6/20/2013 B. inventory of Equipment Tested/Certified Tank m: REGULAR ❑ in Tank Gauging Probe. Model: 19 Annular Space or vault Sir. Model: 420 ® Piping Sump / Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ® Mechanical Line beak Detector. Model: FE PETRO © Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Madel: FLAPPER 13 Other (specify equipment type and model in Section E on Page 2). 1 Tank lD: SUPREME ❑ In -Tank Gauging Probe. Model: Tank M. DIESEL [} in -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 420 1 Piping Sump / Trench Sensor(s). Model: 248 ❑ Fill Sump Sensor(s). Model: ® Mechanical Liao leak Detector. Model: RJ FX1-DV ❑ Electronic Lane Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: FLAPPER ❑ Other (specrfy equipment type and model in Section E on Page 2). Tank ID: ❑ fn -Tank Gauging Probe. Model: ® Annular Space or Vault Senses. Model: 420 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump / Trench Sensor(s). Model. 208 ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s} Model: ❑ Pill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: FE PETRO ❑ Mechanical Line Leak Detector. Model: ❑ Electronic bane Leak Detector. Model: ❑ Electronic Line Leak Detects: Model: 0 Tank Overfill I Straw. Modal: FIAPPeR ❑ Tusk Overfill I High -Level Straw. lAodel: ❑ Other (specify equipmenttype and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: 112 Dispenser ID: 314 ❑ Dispenser Containment Sensor(sj Model: ❑ Dispenser Cantainment Sensor(s). Model: ® Shear Valve(s). 0 Shear Valve(s). 0 Dispenser Containment Float(s) and Chain(s). ® Dispenser Containment Float(s) and Chain(s). Dispenser M. 516 Dispenser ID: 718 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Scraw(s). Model: 0 Shear Valve(s). ® Shear Valve(s). 0 Dish Containment nuat(s) and Chain(s). 0 BispMW cmubrrmt Float(o) and Chmxsj Dispenser M. Dispenser ID: ❑ Ddgxwer Containment Sensor(s). Model: _ ❑ Dispenser Containment Sensor(s). Model: ❑ Shear valve(s). ❑ Shear Valve(s} ❑ Dispenses Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Cbain(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 equi ment. For any equipment capable of generating such reports, I have also attached a copy of the report; (check all that apply): Sy up Mum history report Technician Name Charles Ferruccl Signature: Certification No.: B37512 LiceYase. No.: 952520 Testing Company Name: Service Staion Testing, Inc. Phone No.: (209) 465-5577 Testing Company Address: PO Box 31465 Stockton, Ca 95213 Date of Testing/Servicing: 6120/2013 Page 1 of 3 Rev (2/08)