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® PMONITORING SYSTEM CERTIFICATION For Use By All Junsdiclions Wahin the State of Calofmia Authority Ci0apter 6.7,Health and Safety Code;Chapter 16,Division*3,California 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 insalled at the facility, aaseparat_e_ cediffcation or report must be prepared for each rtaniMng system control panel by the technician who performs the work. A copy of this form must be provided to the tank • system owner .opera or. a owner operator must su mit a copy o is TOM to me local agency regulating UST systems within 30 days of test date. Instructions are printed on the back page. A. General Information Facility Name: CHEVRON 200764 Site Address: 4747 WEST LANE City: STOCKTON CA ZIP:95210 Contact Phone No: 956-2520 Facilty Contact Person: MANAGER Date of Testing/Service: 03/26/2001 Make/Model of Monitoring System:VEEDER ROOT TLS Word Order Number: 2216067 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicate specific equipment inspected/serviced Tank ID: SUPER TanklD: PLUS In-Tank Gauging Probe. Model: TLS 71 In-Tank Gauging Probe. Model: Annular Space orvaun Sensor. Model: Lam- Annular Space or Vault Sensor. Model: TLS -59 Piping Sump/Trench Sensor(s). Model: TLS Piping Sump/Trench Sensor(s). Model: TLS Fill Sump Senors). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: TLS PLLD Electronic Line Leak Detector. Model: TLS PLLD Tank OverfilliHigh-Level Sensor. Model: Tank Overfill/High-Level Sensor. Model: Dispenser Containment Sensor(s) Model: TLS Dispenser Containment Sensors)t Model: TLS Shear Valve(s). Shear Valve(s), Dispenser Containment Flost(s)and Chains(s). Dispenser Containment Float(s)and Chains(s). Other(specify equipment type and model in Section Eon page 2). Other(specify equipment type and model in Section E on page 2). an : REGULAR an In-Tank Gauging Probe. Model: TLS In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: TLS Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: TCS 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: Electronic Line Leak Detector. Model: TLS PLLD Electronic Line Leak Detector. Model: Tank Overfill/High-level Sensor. Model: Tank Overfill/High-level Sensor. Model: -39 Dispenser Containment Sensor(s). Model: 7L7 Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s)and Chains(s). Dispenser Containment Float(s)and Chains(s). Other(specify equipment type and model in Section E on page 2). Other(specify equipment type and model in Section E on page 2). C. Certification I certify that the equipment idendfied in this document was inspected/serviced in accordance with the manufacturer's guidelines. Attached to this certification is information(e.g manufacturer's 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: ANEILCHAND SIGNATURE: %Y COMPANY: Tanknology PHONE NO: (800)800-4633 page 1 of 3 Based on CA torn dated 05/00