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FEB 2 7 2009 �'r'��M70 MONI"RING SYSTEM CERTIF;�TIOP ENVIRONPaIEhJT 1t�L� For se By All Jurisdictions Within the State of Cali ornia Am;kAOy"( I j? jter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California CW . Reg'�1 t(� This form must be used to document testing and servicing of monitoring equipment. A separate certification or r ch monitoring system control panel by the technician who performs the work. A copy of this form must be provided[o 'sy em•_q"p�d�rp�eramr. 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 FacilityName: CHEVRON Bldg.No.: Site Address: 3400 MACARTHUR City: TRACY Zip: 95376 Facility Contact Person: KARAM Contact Phone No.: ( ) Make/Model of Monitoring System: VEEDER-ROOT TLS-350 Date of Testing/Servicing: 2/4/2009 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific a ui ment inspected/serviced: Tank ID: # 1 91 UNLEADED Tank ID: _ ®In-Tank Gauging Probe, Model: 847390-109 M In-rank Gauging Probe. Model: 847390-109 ®Annular Space or Vault Sensor. Model: 794380-302 ®Annular Space or Vault Sensor. Model: 794380-302 ®Piping Sump/Trench Sensor(s). Model: 794380-208 ®Piping Sump/Trench Sensor(s). Model: 794380-208 ®Fill Sump Sensor(s). Model: 794380-208 ®Fill Sump Sensors). Model: 794380-208 ®Mechanical Line Leak Detector. Model: VAPORLESS ❑Mechanical Line Leak Detector. Model: VAPORLESS ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ®Tank Overfill/High-Level Sensor. Model: VEEDER-ROOT ®Tank Overfill/High-Level Sensor. Model: VEEDER-ROOT ❑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: # 2 87 UNLEADED TanklD: ®In-Tank Gauging Probe. Model: 847390-109 ❑In-Tank Gauging Probe. Model: ®Annular Space or Vault Sensor. Model: 794380-302 ❑Annular Space or Vault Sensor. Model: ®Piping Sump/Trench Sensors). Model: 794380-208 ❑Piping Sump/Trench Senors). Model: ®Fill Sump Sensor(s). Model: 794380-208 ❑Fill Sump Seasons). Model: ®Mechanical Line Leak Detector. Model: VAPORLESS ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ®Tank Overfill/High-Level Sensor. Model: VEEDER-ROOT ❑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: 1-2 Dispenser ID: 7-8 ®Dispenser Containment Sensor(s). Model: 794380-208 ❑Dispenser Containment Sensor(s). Model: 794380-208 ❑Shear Valve(s). ❑Shear Valve(s). ❑Dispenser Containment Floats)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 3-4 Dispenser ID: ®Dispenser Containment Sensor(s). Model: 794380-208 ❑Dispenser Containment Sensor(s). Model: / ❑Shear Valve(s). ❑Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5-6 Dispenser ID: ®Dispenser Containment Sensor(s). Model: 794380-208 ❑Dispenser Containment Sensor(s). Model: ❑Shear Valve(s). ❑Shear Valve(s). ❑Dispenser Containment Floatis)and Chain(s). ❑Dispenser Containment Floats)and Cham(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): ® System set-up ® Alarm hi tory repot Technician Name(print): Gregg Geltz Signature: - Certification No.: 5250561-UT License.No.: 491948 Testing Company Name: Central Petroleum Maintenance Phone No.:(925) 462-4060 Site Address: 176 Wyoming Street, Pleasanton CA 94566 Date of Testing/Servicing: 2/4/2009 Page 1 of 3 UN-036-1/4 www.unidms.org Rev.01/26/06