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MONITO� <br />RING SYSTEM CERTIFI TION <br />Use By All Jurisdictions Within the State of Califon <br />Authority Cited: Chapter 6.7, lth and Safety Code; Chapter 16, Division 3 Title 23, California Code of Regulations <br />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 <br />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 <br />system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating LIST systems within 30 days of test date. <br />A. General Information <br />Facility Name: CONOCO PHILLIPS #2708671 <br />Site Address: 8606 THORNTON ROAD <br />Facility Contact Person: MANAGER <br />Make/Model of Monitoring System:TLS-350 <br />B. Inventory of Equipment Tested/Certified <br />Check the appropriate boxes to indicate specific equipment inspected/serviced <br />City: STOCKTON <br />Contact Phone No: 478-8959 <br />Date of Testing/Service: 07/05/2005 <br />Work Order Number: 2237227 <br />CA <br />Zip: 95209 <br />Tank ID: 1-91 <br />Tank ID: 2-89 <br />%( In -Tank Gauging Probe. <br />Model: MAG <br />Z In -Tank Gauging Probe. <br />Model: MAG <br />X Annular Space or Vault Sensor. <br />Model: 409 <br />© Annular Space or Vault Sensor. <br />407 <br />X Piping Sump/Trench Sensor(s). <br />Model: 208 <br />Model: <br />208 <br />Piping Sump/Trench Sensor(s). <br />Model: <br />Fill Sump Sensor(s). <br />Model: <br />El <br />Mechanical Line Leak Detector. <br />Model: F.E. PETRO MLD <br />Fill Sump Sensor(s). <br />X <br />Model: <br />Mechanical Line Leak Detector. <br />Model: LD -2000 <br />Electronic Line Leak Detector. <br />Model: <br />Electronic Line Leak Detector. <br />Model: <br />Tank Overfill/High-Level Sensor. <br />Model: <br />Tank Overfill/High-Level Sensor. <br />Model: <br />Other (specify equipment type and <br />model in Section E on page 2). <br />❑ Other (specify equipment type and <br />model in Section E on page 2). <br />Tank ID: <br />Tank ID: <br />X In -Tank Gauging Probe. <br />Model: MAG <br />In -Tank Gauging Probe. <br />Model: <br />X Annular Space or Vault Sensor. <br />Model: 407 <br />❑ Annular Space or Vault Sensor. <br />Model: <br />X Piping Sump/Trench Sensor(s). <br />Model: 208 <br />Piping Sump/Trench Sensor(s). <br />Model: <br />Fill Sump Sensor(s). <br />Model: <br />Fill Sump Sensor(s). <br />Model: <br />X Mechanical Line Leak Detector. <br />Model: LD -2000 <br />■ Mechanical Line Leak Detector. <br />Model: <br />Electronic Line Leak Detector. <br />Model: <br />Electronic Line Leak Detector. <br />Model: <br />Tank Overfill/High-Level Sensor. <br />Model: <br />❑ Tank Overfill/High-Level Sensor. <br />Model: <br />Other (specify equipment type and model in Section E on page 2). <br />Other (specify equipment type and <br />model in Section E on page 2). <br />Dispenser : 1/2 <br />Dispenser ID: 3/4 <br />❑ Dispenser Containment Sensor(s) <br />Model: <br />❑ Dispenser Containment Sensor(s) <br />Model: <br />X❑ Shear Valve(s). <br />X1 Shear Valve(s) <br />[ Dispenser containment Float(s) and Chain(s). <br />X Dispenser Containment Float(s) and Chain(s). <br />Dispenser ID: <br />Dispenser lD: <br />❑ Dispenser Containment Sensor(s) <br />Model: <br />Dispenser Containment Sensor(s). <br />Model: <br />Shear Valve(s). <br />F-1 Shear Valve(s). <br />Dispenser Containment Float(s) and Chain(s). <br />Dispenser Containment Float(s) and Chain(s). <br />Dispenser lD: <br />Dispenser ID: <br />❑ Dispenser Containment Sensor(s) <br />Model: <br />Dispenser Containment Sensor(s). <br />Model: <br />❑ Shear Valve(s). <br />■ Shear Valve(s). <br />10 Dispenser Containment Float(s) and Chain(s). <br />Dispenser Containment Float(s) and Chain(s). <br />If the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facility. <br />C. Certification <br />I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. <br />Attached to this certification is information (e.g manufacturers' checklists) necessary to verify that this information is correct. <br />and a Site Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached <br />a copy of the (Check all that apply): ❑ System set-up 0 Alarm history report <br />/Y7 <br />Technician Name (print): JOEY MESA Signature: e <br />Certification No.: 06-005-1532 License. No.: <br />Testing Company Name:Tanknology Phone No.: (800) 800-4633 <br />Site Address: 8501 N. MoPac Expressway, suite 400, Austin, TX 78759 Date of Testing/Servicing: 07/05/2005 <br />Monitoring System Certification Page 1 of 3 Based on CA form dated 03/01 <br />