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Nov 14 12 11:40a Reliable PetroleumA 209-845-8953 p.2 MONI ORING SYSTEM CERTIFIfATION For Use By All Jurisdictions Within the State of California Authority Cued: apter 6.7,Health and Safety Code;Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to it testing and servicing of monitoring equipment. A separate ceriifica[ion or report must be prepared for each monitorin tem ontrol el by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The owneriaperator must su it a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Inforina ion FacilityName: CHEVRON Bldg.No.: Site Address: 508 W.C arter Wa City: Stockton,Ca. Zip: 95206 Facility Contact Person: I 9nku Contact Phone No.: (209) 465.3440 Make/Model of Monitori System: Veeder-Root TLS-350 Date of Testing/Servicing: 10/1512012 B. Inventory of Eq pment Tested/Certified Check the appropriate boxes a indicate specifict ui ment inspected/serviced: Tank ID: T1: 87 Tank in: T2:91 [I In-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: Z Annular Space or Vault Sere r. Model: 794390320 ®Annular Space or Vault Sensor. Model: 794390320 Z Pipiog Sump t Trench Scnaor Model: 794380-208 0 Piping Sump t Trench Scasons). Model: 794360-208 ❑Fill Sump Scnsor(s). Model: ❑Fill Sump Sensor(s). Model: ❑Mechanical Line Leak Detec r. Model: ❑Mechanical Line Leak Detector. Model: ®Electronic Line leak Detect Model: 6484 Electronic Line Leak Detector. Model: 8484 ❑'Tank Overfill!High-Lcvd 5 son ModcL ❑Tank Overfill!High-Level Sensor. Model: 11 Other(specify equipment hp and model in Section E on Page 2). ❑Other(specify equipment type and model in Section E on Page 2). Took ID: T3: Dlesel I Tank ID: ❑In-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: Z Armular Space or Vault Sens Model: 794390420 ❑Annular Space or Vault Sensor. Model: Z Piping Sump/Trench Sensor ). Model: 794380-208 ❑Piping Sump,(Trench Sensor(s). Mode): ❑Fill Sump Sense.(s). Model: ❑Fill Sump Sensor(s). Model'. ❑Mechanical Line Leak DeteeIn Model: [],Mechanical Line Leak Detector. Model: ®Electronic Line IrakDetetro 48 Model: 84 ❑Electronic Line Leak Detector. Model: ❑Tank Overfill I High-Level 5 nsor. Model: El Tank Overfill/Fligh-Level Sensor. ModA: ElOther(specify equipment typ and model in Section E an Page 2). (1 Other(specify equipment type and model in Section E on Page 2). Dispenser ID: 1&2 Dispenser ID: 38x4 ❑ Dispenser Containment Sens (s). Model, ❑Dispenser Containment Sensor(s). Model: ® Shear Valve(s). 0 Shear Valve(s). ®Dispenser Containment Floa )and Chain(s). Z Dispenser Containment Float(s)and Chain(s). if Dispenser to: 5&6 Dispenser tD: 7&8 ❑Dispenser Containment Sense(s). Model: ❑Dispenser Containment Sensor(s). Model: ®Shear Valm(s). ®Shear Valve(s). ®Dispenser Containment Float i)and Chain(s). ®Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑Dispenser Containment Sens (s). Model: ❑Dispenser Containment Sensor(s). Model: ❑Shear Valve(s). ❑Shear Valm(s). ❑Dispenser Containment Float()and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). *If the facility contains more I mks or dispensers,copy this form. Include information for every tank and dispenser at the facility. C. Certification - 1 er[ify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' gaideli es. Attached to this Certification is information (e.g. manufacturers' checklists)necessary to verify that this information is correct ind a Plot Plan showing the layout of monitoring eq m ment. For any equs went capable of generating such reports,I have also atts had a copy of the report;(check all that Appiy): System Set-up Alarm hnnorry report i Technician Name(print): 3uadalupe Sanchez Signature-- Certification ignatur--Certification No.: A30131 License.No.: 883706 Testing Company Name: eliable Petroleum Services, Inc. Phone No.:(209) 846-8586 Testing Company Address 11930 Horseshoe Rd. Oakdale,Ca.95361 Date of Testing7Servicing: 1011512012 Page 1 of 4 Rev(2/08)