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ant�i rk y �uSystem E i me ter icatio � For Use By All Jurisdictions Within The State of California ,authority Cited, Chapter 6.7, Health sand 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 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 Site Address: 6633 Pacific Ave Bldg. No.: City: Stockton, CA Zip: 95207.3719 Facility Contact Person: Manager Contact Phone No.: (209) 477-4294 Make/Model of Monitoring System: V/R TLS -350 B. Inventory of Equipment Tested/Certified Check the aanronriate hnxps to indicatesneeific equipment inspected/serviced: Date of Testing/Servicing: 2/1113 Tank II)• 01 -Prem Tank IT).- 02 -Rego ❑ In - Tank Ganging Probe. Model: VR 847390.107 ❑ In - Tank Gauging Probe. Model: VR 847380.107 ❑ Annular Space or Vault Sensor. Model: VR794390-409 ❑ Annular Space or Vault Sensor. Model: VR 794390-409 ❑ Piping Sump \ Trench Sensor (s). Model: VR 794380-352 ❑ Piping Sump \ Trench Sensor (s).. Model: VR 794380-352 ❑ Fill Sump Sensor (s). Model: VR 794380.208 ❑ Fill Sump Sensor (s). Model: VR 794380.20a ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model ® Electronic Line Leak Detector, Model: VR series 8484 ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill \ High -Level Sensor. Model: ❑ Tank Overfill \ High -Level Sensor. Model: ❑ Other ( specify equipment type and model in Section E on Page 2). ❑ Other ( specify equipment type and model in Section E on Page 2). Tank fD• 03 -Rego Tank. ID ❑ In - Tank Gauging Probe. Model: VR 847390.107 ❑ In - Tank Ga -aging Probe, Model: ❑ Annular Space or Vault Sensor. Model: VR 794390.409 ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump 1 Trench Sensor (s). Model: VR 794380-352 ❑ Piping Sump \ Trench Sensor (s), Model: ❑ Fill Sump Sensor (s). Model: VR 794380-208 ❑ Fill Sump Sensor (s). Ivlodel:. ❑ Mechanical Line Leak Detector. Model_ ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: VR Series 8484 ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill \ high -Level Sensor. Model: ❑ Tank Overfill \ I iigh-Level Sensor. Model: ❑ 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 W. 01-02 Dispenser ID- 03-04 ❑ Dispenser Containment Sensor (s). Model: VR 794380-208 ❑ Dispenser Containment Sensor (s), Model: VR 794380.208 ❑ Shear Valve (s). ❑ Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). 05-06 Dispenser ID 07-08 penser ID: Dispenser Containment Sensor (s), .Model VR 794380-208 ❑ Dispenser Containment Sensor (s), .Model: VR 794380.208 Shear Valve (s). FO— ❑ Shcar Valve (s). Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). enser ID• 09-10 ispenser Containment Sensor (s). hear Valve (s).Shear F�D ispenseroutairlment Float (s) and Model:VR794380-208 Chain (s). Dispenser ❑ ❑ ID• 11-12 Dspenser Containment Sensor (s). Valve (s). Dispenser Containment Float (s) and Model:VR 794380.208 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 manufacturer's guidelines. Attached to this Certification is information (e.g, manufactures' 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; (check all thstrpptv). ❑ System set-up Technician Name (print): Kris Bell Signature: Mfg. Cert.# B33709 TCC# 5297793 -UT N Alarm history report License. No.: 485184 Testing Company Name: Service Station Systems Phone No.: (408) 971-2445 Testing Company Address: 680 Quinn Ave., San Jose, CA 96112 Date of Testing/Servicint=_: 211/13