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Appendix V1 4( RECEIVED MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California 2.11" L Authority Cited:Chapter 6.7,Health and Safety Code;Chapter 16,Division 3,Title 23,California Code of ns This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must bere o LT each monitoring system control panel by the technician who performs the work.A copy of this form must be pro owner/operator.The owner/operator must submit a copy of this form to the local agency regulating UST systems m 'mfg A. General Information Facility Name: LOWER SAC CHEVRON Bldg.No.: Site Address: 8660 LOWER SAC City: STOCKTON CA Zip: Facility Contact Pr:rann- KAMAL Contact Phone No.: (925)984-5960 Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 10/15/2012 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific a ui ment inspected/serviced: Tank ID: 87 OCT Tank ID: 89 OCT ® In-Tank Gauging Probe. Model: MAG 1 ® In-Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 407 ® Annular Space or Vault Sensor. Model: 407 ® Piping Sump/Trench Sensor(s). Model: 352 ® Piping Sump/Trench Sensor(s). Model: 352 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detecticx. Model ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: PLLD ® Electronic Line Leak Detector. Model: PLLD ❑ 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: 91 OCT Tank ID: NA ® In-Tank Gauging Probe. Model: MAG 1 ❑ In-Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 407 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump/Trench Sensor(s). Model: 352 ❑ 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: PLLD ❑ Electronic Line Leak Detector. Model: •F 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). aispenser ID: 9-2 Dispenser ID: 5-6 ® Dispenser Containment Sensor(s). Model: 322 ® Dispenser Containment Sensor(s). Model: 322 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 3.4 Dispenser ID: 7-8 ® Dispenser Containment Sensor(s). Model: 322 ® Dispenser Containment Sensor(s). Model: 322 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: El Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: 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 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): DAVE WINKLER Signature: `T� Certification No.: 5263373-UT License No: 08-1739 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 Z STREET GALT,CA 95632 Date of Testing/Servicing: 10-15-2012 Monitoring System Certification Page 1 of 4 2/21/07 5