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MONI-ORING SYSTEM CERTIFIWTION 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 CED This form must be used to document testing and servicing of monitoring equipment. A separate certification or repo s 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 sypT o"rj�#tor. 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: Hammer Lane Chevron Site Address: 3304 W. Hammer Lane Facility Contact Person: Mike Make/Model of Monitoring System: Veeder Root TLS -350 B. Inventory of Equipment Tested/Certified Check the atitirotiriate boxes to indicate stiecific eattitiment inspected/serviced: F11i _N\fjR0NMENTAL HEAL WrISERvICES Bldg. City: Stockton, Ca. Zip: 95619 Contact Phone No.: (209) 478-9293 Date of Testing/Servicing: 6121/2012 Tank ID: TI: 87 Tank ID: T2: 91 [I In -Tank Gauging Probe. Model: El In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 794390-420(Split-Tank) Annular Space or Vault Sensor. Model: 794390-420(Split-Tank) Piping Sump / Trench Sensor(s). Model: 794380-208 Piping Sump / Trench Sensor(s). Model: 794380-208 El Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Z Mechanical Line Leak Detector. Model: FE Petro STP -MLD Mechanical Line Leak Detector. Model: FE Petro STP -MLD El Electronic Line Leak Detector. Model: El Electronic Line Leak Detector. Model: 0 Tank Overfill / High -Level Sensor. Model: [] Tank Overfill / High -Level Sensor. Model: El Other (specify equipment type and model in Section E on Page 2). El Other (specify equipment type and model in Section E on Page 2). Tank ID: T3: Diesel Tank ID: El In -Tank Gauging Probe. Model: [:1 In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 794390-420 El Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: 794380-208 E] Piping Sump / Trench Sensor(s). Model: El Fill Sump Sensor(s). Model: El Fill Sump Sensor(s). Model: Z Mechanical Line Leak Detector. Model: RJ FX1 DV 0 Mechanical Line Leak Detector. Model: El Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: M Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: 0 Other (specify equipment type 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 El): 3&4 El Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). Z Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5&6 Dispenser ID: 7&8 El Dispenser Containment Sensor(s). Model: [I Dispenser Containment Sensor(s). Model: Shear Valve(s). Z Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Z Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: El Dispenser Containment Sensor(s). Model: El Dispenser Containment Sensor(s). Model: E] Shear Valve(s). E] Shear Valve(s). El Dispenser Containment Float(s) and Chain(s). El Dispenser Containment Float(s) and Chain(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 equipment. For any equipment capable of generating such reports, I have also attached a copy of the report; (check all that apply): Z System set-up Z Alarmhistory report �f Technician Name (print): Guadalupe Sanchez Signature: - Am i55i� Certification No.: A30138 License. No.: 883706 Testing Company Name: Reliable Petroleum Services, Inc. Phone No.: (209) 845-8686 Testing Company Address: 11930 Horseshoe Rd. Oakdale, Ca.95361 Date of Testing/Servicing: 6/2112012 Page I of 4 Rev (2/08)