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t Monitoringfication _._ i For Use By All Jurisdictions Within The Stute of Culiforniu Authori(y Cited.Chapter 6.7• Health and Sqfety Conde; Chapter 16, Division 3„ Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate 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 system within 30 days of test date. A. General Information Facility Name: Chevron Bldg.No.: Site Address: 2905 W.Benjamin Holt Dr City: Stockton,CA Lip: 95207-3217 Facility Contact Person: r y\c.�- � _ Contact Phone No.: (209)478-5555 Make/Model of Monitoring System: V JLC I t-s 3 SZ) Date of Testing/Servicing: 7128110 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicate specific equipment inspected/serviced: Tank iD 8�l Tank ID• ❑ In-'Tank Gauging Probe. Model: ❑ to-'rank Gauging Probe. Modet: ❑ Annular Space or Vault Sensor. Mojcl: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump\Trench Sensor(s). Model: ❑ Piping Sump\french Sensor(s). Model: fila. Fill Sump Sensoris). Model: ?_cA ❑ fill Sump Sensor(s). Model: ❑ 'Mechanical tine teak Daector. Model: ❑ Mechanical Line Lcak Detector. ModeC ❑ Electronic tine teak Detector. Madel: ❑ Electronic I..inc teak.Doectoc Model! ❑ 'rank Overfill\Bich-Level Sensor. Model: ❑ Tank Overfill\High-t.evel Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section L on Page 2). TankIQ: TankIQ. ❑ In-Tank Gauging Probe. Malek ❑ In-Tank Gauging Probe. Modell ❑ Annular Space or Vault Sensor. Model: ❑ Annular Spa"or Vault Sensor. Madel: ❑ Piping Sump\Trench Sensor(s). Model: ❑ Piping Sump\Trench Sensor(s). Model: ❑ fill Sump Sensor(s). Model: ❑ fill Sump Sensor(s). Model: ❑ Mechanical Line Leal:Detector. Model: ❑ Mechanical lane teak Detector. Model: ❑ P.lectronic Line Leak Detector. Model: ❑ Electronic Line i.tak t)ctector. Model., ❑ 'rank Overfill\Iligh-Level Sensor, !bode!: ❑ Tank Overfill\Iligh-Level Sensor. Model:. ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model ir: section E on Page 2)• Dispenser IQ* Dispenser iQ: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment float(s)and Chain W. ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID• Dispenser iD• ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor is). Mr.ch l: ❑ Shear Valve(s). ❑ Shear Valve(s)_ ❑ Dispenser Containment float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser IQ: Dispenser ID• E3 Dispenser Containment Sensor(s). Model: [I Dispenser Containment Sensor(sl. Model: ❑ Shear Valve(s). ❑ Shear Valve W. ❑ Dispenser Containment Float(,$)and Chain(s). ❑ 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- 1 certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturer's guidelines. Attached to this Certification is information(e.g.manufactures'checklists)necessary tp veriry that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable oif generating such reports,t have also attached a copy of the, (check all that apply): d5 System set-up 00 Alarm history report Technician Name(print)• Bryan Lundlen Signature: Mfg.Ccrt.#.; 3 to OS 4 ICC# Q LIN 4!.k- U A License. 184 Testing Company Flame: SSS Phone No.: (408)971-2445 Testing Company Address: 680 Quinn Ave.,San Jose,CA 95112 Date of resting/Servicing: 7128110