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e MONOPRING SYSTEM CERTISATION For Use By All Jurisdictions Within the State of Ca i ornia Authority Cited.• Chapter 6.7, Health and 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 systems within 30 days of test date. A. General Information Facility Name: CHEVRON Bldg.No.: Site Address: 508 W. Charter Way City: Stockton, Ca. Zip: 95206 Facility Contact Person: Rinku Contact Phone No.: (209) 465-3440 Make/Model of Monitoring System: Veeder- Root TLS-36010/10/2013 10/10g /2013 B. Inventory of Equipment Tested/Certified RC Clvt� Check the appropriate boxes to indicates ectfic a ui ment inspected/serviced. Tank ID: T1: 87 Tank ID: T2: 91 M ❑In-Tank Gauging Probe. Model: E] In-TankGauging PmbENVIRONMM IAL ®Annular Space or Vault Sensor. Model: 794390420 Z Annular Space or Vault SerPERMIT?,#f&1/ Z Piping Sump/Trench Sensor(s). Model: 794380-208 Z Piping Sump/Trench Sensor(s). Model: 79 80-208 ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑Mechanical Line.Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: Z Electronic Line Leak Detector. Model: 8484 Z Electronic Line Leak Detector. Model: 8484 ❑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 to: T3: Diesel Tank ID: ❑In-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: Z Annular Space or Vault Sensor. Model: 794390420 ❑Annular Space or Vault Sensor. Model: Z Piping Sump/Trench Sensor(s). Model: 794380-208 ❑ Piping Sump/Trench Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: Z Electronic Line Leak Detector. Model: 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: 1&2 Dispenser ID: 3&4 ❑Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Z Shear Valve(s). Z Shear Valve(s). Z Dispenser Containment Floats)and Chain(s). Z Dispenser Containment Float(s)and Chain(s). Dispenser ID: 58,6 Dispenser ID: 7&8 ❑Dispenser Containment Sensors). Model: ❑Dispenser Containment Sensor(s). Model: Z Shear Valve(s). Z Shear Valve(s). Z Dispenser Containment Float(s)and Chain(s). Z Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: ❑Shear Valve(s). ❑Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Floats)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 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): E System set-up ® Alarm histo report Technician Name(print): Guadalupe Sanchez :Signature, Certification No.: A30138 License.No.: 883706 Testing Company Name: Reliable Petroleum Services, Inc. Phone No.:(209) 845-8586 Testing Company Address: 11930 Horseshoe Rd. Oakdale, Ca.95361 Date of Testing/Servicing: 10/10/2013 Page 1 of 4 Rev(2/08)