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Monitoring System Equipment e c 'on 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 ofRegulations This form must be used to document testing and servicing of monitoring equipment. A so=e certificatign or report must be prepared for each monitorings sy tem 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 I Bldg. No.: Site Address: 6633 Pacific Ave 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 Date of Testing/Servicing: 1114113 B. Inventory of Equipment Testeclertified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank I%01 -Prem Tank ID: 02-Regu ® In -Tank Gauging Probe Model: VR 847390-407 0 In - Tank Gauging Probe. Model: VR 8473x0407 ® Annular Space or Vault Sensor. Model: VR 794390408 11 Annular Space or Vault Sensor. Model: VR 794380.408 R Piping Sump \ Trench Sensor (s). Model: VR 796980.952 ® Piping Sump \ Trench Sensor (s). Model: VR 794380-352 ® Fill Sump Sensor (s). Model: VR 784380-208 8 Fell Sump Sensor (s). Model: VR 786380208 ❑ 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 ID: 03-Regu _ Tank M! ® In - Tank Gauging Probe. Model: VR 847390407 ❑ In - Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: VR t943ea.609 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump \ Trench Sensor (s). Model: VR 794380252 ❑ Piping Sump \ Trench Sensor (s). Model: ® Fill Sump Sensor (s). Model: VR 784380.208 ❑ Fill Sump Sensor (s). Model: ❑ 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). Dispenser ID• 01-02 Dispenser ID: 03-04 ® Dispenser Containment Sensor (s). Model: VR 784380208 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). Dispenser 1D: 05-00 Dispenser M: 07-08 ® Dispenser Containment Sensor (s). Model: VR 704380,208 Dispenser Containment Sensor (s). Model: VR 704350.208 ❑ Shear Valve (s). ❑ Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser M- 09"10 Dispenser iD: 1142 ® Dispenser Containment Sensor (s). Model: VR 784380.206 ® Dispenser Containment Sensor (s). Model: VR 79636x298 ❑ Shear Valve (s). ❑ Shear Valve (s). ❑ Dispenser Containment Float (s) 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 - 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-, (checkati ftratapft): ® System set-up ® Alarm history report Technician Name (print): Roamon Frazier Signature. Mfg. Cert.#.: 837362 ICC# 8020732 -UT License. No.: 485184 Testing Company Name: Service Station Systems Phone No.: (408) 971-2445 Testing Company Address: 680 Quinn Ave., San Jose, CA 95112 Date of Testing/Servicing: 1114113