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MONITNG SYSTEM CERTIFIC TION se By All Jurisdictions Within the State of Californh Authority Cited: Chapter 6.7, He h and Safety Code; Chapter 16, Division 3 Title 23, G .-omia Code of Regulations This form must be used to document testing and servicing of monitoring equipment. If more than one monitoring system control panel is installed at the facility, 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 systems within 30 days of test date. A. General Information Facility Name: CHEVRON 307709 Site Address: 10858 TRINITY PKWY City: STOCKTON Contact Phone No: 952-2213 Date of Testing/Service: 09/14/2009 Facility Contact Person: MANAGER Make/Model of Monitoring System:TLS 350 Work Order Number: 2269078 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced CA Zip: 95210 Tank ID: 87 Tank ID: 91 %( In -Tank Gauging Probe. Model: MAG ❑X In -Tank Gauging Probe. Model: MAG X Annular Space or Vault Sensor. Model: 303 ❑X Annular Space or Vault Sensor. Model: 303 X Piping Sump/Trench Sensor(s). Model: 208/304 Piping Sumplfrench Sensor(s). Model: 208/ 304 X Fill Sump Sensor(s). Model: 208/304 ® Fill Sump Sensor(s). Model: 208/304 X Mechanical Line Leak Detector. Model: STP MLD ❑X Mechanical Line Leak Detector. Model: LD 2000 Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: X Tank Overfill/High-Level Sensor. Model: FLAPPER/EXTERNAL ALARM ® Tank Overfill/High-Level Sensor. Model: FLAPPER/EXTERNAL ALARM Other (specify equipment type and model in Section E on page 2). 0 Other (specify equipment type and model in Section E on page 2). Tank ID: TanklD: 71 In -Tank Gauging Probe. Model: MAG In -Tank Gauging Probe. Model: X Annular Space or Vault Sensor. Model: 303 Annular Space or Vault Sensor. Model: X Piping Sump/Trench Sensor(s). Model: 208/304 Piping Sump/Trench Sensor(s). Model: X Fill Sump Sensor(s). Model: 208/304 ❑ Fill Sump Sensor(s). Model: X Mechanical Line Leak Detector. Model: LD 2000 ❑ Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: FLAPPER/EXTERNAL ALARM 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 : 1/2 Dispenser ID: 3/4 ® Dispenser Containment Sensor(s) Model: 208/304 X Dispenser Containment Sensor(s) Model: 208/304 X❑ Shear Valve(s). X Shear Valves) ❑ Dispenser Containment Float(s) and Chain(s). 7 Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5/6 Dispenser ID: 7/8 X❑ Dispenser Containment Sensor(s) Model: 208/304 ❑X Dispenser Containment Sensor(s). Model: 208/304 X❑ Shear Valve(s). ® Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: 9/10 Dispenser ID: 11/12 X❑ Dispenser Containment Sensor(s) Model: 208/304 X❑ Dispenser Containment Sensor(s). Model: 208/304 QX Shear Valve(s). ❑X 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 manufacturers' guidelines. Attached to this certification is information (e.g manufacturers' checklists) necessary to verify that this information is correct. and a Site 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 that apply): ❑ System set-up X❑ Alarm history report Technician Name (print): STEVEN WILLEMS Signature: Certification No.: 836743 License. No.: 743160 (Class 'A' General Enginering Contractor License) Testing Company Name:Tanknology Phone No.: (800) 800-4633 Site Address: 11000 N. MoPac Expressway, suite 500, Austin, TX 78759 Date of Testing/Servicing: 09/14/2009 Monitoring System Certification Page 1 of 3 Based on CA form dated 03/01