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MONITORING SYSTEM CERTIFICATION se By All Jurisdictions Within the State of Cal'tomi Authority Cited: Chapter 6.7, and Safety Code; Chapter 16, Division 3 Title 23,mia Code of Regulations This form must be used to document testing and A. General Information Facility Name: CHEVRON 91452 of monitoring equipment. If more than one monitoring system control panel is installed at the facility, a separate 7 system control panel by the technician who performs the work. A copy of this form must be provided to the tank a copy of this form to the local agency regulating UST systems within 30 days of test date. City: RIPON Site Address: 334 E. MAIN ST Contact Phone No: 599-2313 Q HWY 99 Date of Testing/Service: 01/12/2007 Facility Contact Person: DEALER - DONNA Make/Model of Monitoring System:VR TLS350 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced Work Order Number: 2246710 CA Zip: 95366 Tank ID: SUPREME Tank ID: PLUS X 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 _X1 Piping Sump/rrench Sensor(s). Model: 206208 Piping Sump/french Sensar(s). Model: Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: X Electronic Line Leak Detector. Model: VR - PLLD )t Electronic Line Leak Detector. Model: VR - PLLD X1 Tank Ovefill/High-Level Sensor. Model: MAG Tank Overfill/High-Level Sensor. Model: MAG 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 ID: Tank ID: 71 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: )( Piping Sump/rrench Sensor(s). Model: 208 Piping Sump/rmnch 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: VR - PLLD Electronic Line Leak Detector. Model: 71 Tank Overfill/High-Level Sensor. Model: MAG Tank OveKll/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: 7/8 ❑X Dispenser Containment Sensor(s) Model: 208 X Dispenser Containment Sensor(s) Model: 208 X❑ Shear Valve(s). _X-1 Shear Valve(s) Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: 3/4 Dispenser ID: FT Dispenser Containment Sensor(s) Model: 208 Dispenser Containment Sensor(s). Model: X❑ Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5/6 Dispenser ID: XD Dispenser Containment Sensor(s) Model: 208 Dispenser Containment Sensor(s). Model: XJ Shear Valve(s). Shear Valve(s). ID Dispenser Containment Float(s) and Chaln(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): M System set-up X❑ Alarm history report Technician Name (print): TREVOR HANSEN Certification No.: Signature: License. No.: Testing Company Name: Tanknology Phone No.: (800) 800-4633 Site Address: 8501 N. MoPac Expressway, suite 400, Austin, TX 78759 Date of Testing/Servicing: 01/12/2007 Monitoring System Certification Page 1 of 3 Based on CA form dated 03/01