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® Ill - Y MONITORING SYSTEM CERTIFICATION r Use By All Jurisdictions Within the State of Cali Authority Cited:Chapter 6. alth and Safety Code; Chapter 16,Division 3 TitleWalifomia 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 ora rim must be prepared for each monitoring system control panel by the technician who performs the work. A copy of this torte must be provided to the tank system owner operator. a owner operator mus su mite copy o thus o"tote local agency regulating UST systems within 30 days of test date. A.General Information Facility Name: CHEVRON 200764 City: STOCKTON CA Zip:95210 Site Address: 4747 WEST LANE Contact Phone No:956-2520 Facility Contact Person: MANAGER Date of Testing/Service: 03/14/2002 Make/Model of Monitoring System: VR TLS-350 Work Order Number: 2221349 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced Tank ID: SUP TanklD: PLS In-Tank Gauging Probe. Model: 847380-109 In-Tank Gauging Probe. Madel: 847380-109 71 Annular Space or Vault Sensor. Model: 794390-407 X Annular Space or Vault Sensor. Model: 794390-407 Piping SumplTrench Sensor(s). Model: 794380-208 X in Sum 794380-208 Piping g p?rench Sensor(s). Model: Fill Sump Sensor(s). Madel: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: 331196-001 X Electronic Line Leak Detector. Model: 331196-001 Tank OveriilUHigh-Level Sensor. Model: 61SO X Tank Overfill/High-Level Sensor. Model: 61SO Other(specify equipment type and model in Section E on page 2). Other(specify equipment type and model in Section E on page 2). an an In-Tank Gauging Probe. Model: 847380-109 In-Tank Gauging Probe. Model: Annular Space or Vault Sensor, Model: Annular Space or Vault Sensor. Model: Piping SumplTrench Sensor(s). Model: 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: 71 Electronic Line Leak Detector. Model: 331196-001 Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: Tank OverfiltMigh-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). Spenser ® Dispenser Containment Sensor(s) Model:794380-208 Dispenser Containment Sensors) Model:794380-208 ® Shear Velvets). Shear Valve(s) ❑ Dispenser Containment Float(s)and Chain(s). 7 Dispenser Containment Float(s)and Chain(s). IspenserDispenser Lr MDispenser Containment Sensors) 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). DispenserlD: 5/6 Dispenser ID: MDispenser 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 Flost(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 report; ® Alarm history report PRINTED NAME MICHAEL T LEVESQUE SIGNATURE: COMPANY: Tanknology PHONE NO: (800)800-4633 page 1 of 3 Based on CA form dated 03/01