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MONIT$WNG SYSTEM CERTIFIWION e By All Jurisdictions Within the State of Califomi 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. If more than one monitoring system control panel is installed at the facility, 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 91452 City: RIPON Site Address: 334 E. MAIN ST Contact Phone No: 599-2313 @ HWY 99 Date of Tesfing/SerAce: 01/04/2006 Facility Contact Person: DEALER - DONNA Make/Model of Monitoring System:VR-TLS350 Work Order Number: 2240141 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced CA Zip: 95366 TanklD: 1 TanklD: 2 -R1 In -Tank Gauging Probe. Model: MAG X In -Tank Gauging Probe. Model: MAG X Annular Space or Vault Sensor. Model: 409 Annular Space or Vault Sensor. Model: 409 X Piping SumprTrench Sensor(s). Model: 208208 Piping Sump/Tranch Sensor(a). 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: PLLD :X:1 Electmric Line Leak Detector. Model: PLLD Tank Overfill/High-Level Sensor. Model: EXT. ANNUNCIATOR X Tank Overfill/High-Level Sensor. Model: EXT. ANNUNCIATOR Other (specify equipment type and model in Section E on page 2) Other (specify equipment type and model in Section E on page 2). TanklD: 3 TanklD: X In -Tank Gauging Probe. Model: MAG In -Tank Gauging Probe. Model: X Annular Space or Vault Sensor. Model: 409 Annular Space or Vault Sensor. Model: X Piping Sumprrmnch Sensor(s). Model: 208 Piping Sumpri-rench Sensor(s), Model: Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: X Electmnic Line Leak Detector. Model: PLLD Electronic Line Leak Detector, Model: X Tank Overfill/High-Level Sensor. Model: EXT. ANNUNCIATOR 7Tank Overall/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 1/2 Dispenser ID: 3/4 MDispenser Containment Sensar(s) Model: 208 —xj Dispenser Containment Sensor(s) Model: 208 X� Shear Valve(s). X Shear Valve(s) ElDispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5/6 Dispenser ID: 7/8 Q Dispenser Containment Sensoria) Model: 208 71 Dispenser Containment Sensor(s). Model: 208 X❑ Shear Valve(s). Shear Velvets). Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: Dispenser Containment Sensors) Model: 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). 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): R System set-up X❑ Alarm history report Technician Name (print): KELVIN CRUZ Certification No.: 006-05-1503 Signature: License. No.: Testing Company Name:Tanknology Phone No.: (800) 8004633 Site Address: 8501 N. MoPac Expressway, suite 400, Austin, TX 78759 Date of Testing/Servicing: 01/04/2006 Monitoring System Certification Page 1 of 3 Based on CA form dated 03/01