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MONIr RING SYSTEM CERTIF: -TION For Use By All Jurisdictions Within the State of California ��Authority Cited: Chapter 6.7, Health andSafety Code;Chapter 16, Division 3, Title 23, CaliforniaBEXfif This form must be used to document testing and servicing of monitoring equipment. A separate certification or report mqA 4tpWnared for each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank s s m rator. The owner/operator must submit a copy of this forth to the local agency regulating UST systems within 30 days of test date. A. General Information ENVIRONMENTAL HEALTH PERMIT/SERVICES Facility Name: West Valley Chevron Bldg.No.: Site Address: 2615 W.Grant Line Rd. City: Tracy Zip: 95304 Facility Contact Person: Linda Contact Phone No.: (209) 836-3464 Make/Model of Monitoring System: Veeder Root TLS-350 Date of Testing/Servicing: 3/25/2015 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/sen iced: Tank ID: T1: 91 Tank ID: T2: Diesel Z In-Tank Gauging Probe. Model: 847390-107 Z In-Tank Gauging Probe. Model: 847390-107 Z Annular Space or Vault Sensor. Model: 794380-303(Split tank) Z Annular Space or Vault Sensor. Model: 794380-303(Split Tank) Z Piping Sump/Trench Sensor(s). Model: 794380-208 Z Piping Sump/Trench Sensor(s). Model: 794380-208 Z Fill Sump Sensor(s). Model: 794380-208 Z Fill Sump Sensor(s). Model: 794380-208 ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: Z Electronic Line Leak Detector. Model: 8484 Z Electronic Line Leak Detector. Model: 8484 ❑Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill/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). Tank ID: T3: 87 Tank ID: Z In-Tank Gauging Probe. Model: 847390-109 ❑ In-Tank Gauging Probe. Model: Z Annular Space or Vault Sensor. Model: 794380-303 ❑Annular Space or Vault Sensor. Model: Z Piping Sump/Trench Sensor(s). Model: 794380-208 ❑ Piping Sump/Trench Sensor(s). Model: Z Fill Sump Sensor(s). Model: 794380-208 ❑Fill Sump Sensor(s). Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: Z Electronic Line Leak Detector. Model: 8484 ❑Electronic Line Leak Detector. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill/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: 182 Dispenser ID: 384 Z Dispenser Containment Sensor(s). Model: 794380-208 Z Dispenser Containment Sensor(s). Model: 794380-208 Z Shear Valve(s). Z Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 586 Dispenser ID: 788 Z Dispenser Containment Sensor(s). Model: 794380-208 Z Dispenser Containment Sensor(s). Model: 794380-208 Z Shear Valve(s). Z Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 9810 Dispenser ID: 11812 Z Dispenser Containment Sensor(s). Model: 794380-208 Z Dispenser Containment Sensor(s). Model: 794380-208 Z Shear Valve(s). Z 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 Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attached a copy of the report;(check all that apply): ® System set-up ® Alarm history report Technician Name(print): Guadalupe Sanchez Signature: _< <�� ,. 1dz Certification No.: A30138 License.No.: 883706 Testing Company Name: Reliable Petroleum Services, Inc. Phone No.:(209) 845-8586 Testing Company Address: 11930 Horseshoe Rd. Oakdale, Ca.95361 Date of Testing/Servicing: 3125/2015 Page 1 of 4 Rev(2/08)