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NI NG SYSTEM CERTIFI TION For Use By All Jurisdictions Within the State of California 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. A sqparate certification or opgMULt be prepared for each monitoring system control panel by the technician who performs the work. A copy of this form must be provided t $ tor. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test a e. A. General Information SEP 2 9 2011 Facility Name: Lower Sac Chevron Ede®®1J314g.No.: Site Address: 8660 Lower Sacramento Rd. City: Stockton,Ca. PER ZV"UALT�j Facility Contact Person: Kamal Contact Phone No.: (209) 477-28 Make/Model of Monitoring System: Veeder-Root TLS-350 Date of Testing/Servicing: 9/8/2011 B. Inventory of Equipment Tested/Certified Check the approLnate boxes to indicates ific vi went ins ted/serviced: Tank m: T1: 91 Tank ID: T2: 89 ❑In-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: ®Annular Space or Vault Sensor. Model: 794390-407 ®Annular Space or Vault Sensor. Model: 794390.407 ®Piping Sump/Trench Sensor(s). Model: 794380-352 ®Piping Sump/Trench Sensor(s). Model: 794380452 ❑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: 8484 ®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: ❑In-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: ®Annular Space or Vault Sensor. Model: 794390-409 ❑Annular Space or Vault Sensor. Model: ®Piping Sump/Trench Sensor(s). Model: 794380-352 ❑Piping Sump/Trench Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ED Fill Sump Sensor(s). Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ®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: 1&2 Dispenser ID: 3&4 ®Dispenser Containment Sensor(s). Model: 794380-322 ®Dispenser Containment Sensor(s). Model: 794380-322 ®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: 7&8 ®Dispenser Containment Sensor(s). Model: 794380-322 ®Dispenser Containment Sensor(s). Model: 794380-322 ®Shear Valve(s). ®Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensor(s). 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 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 alt that apply): ®System set-up ®Alarm history report Technician Name(print): Guadalupe Sanchez Signature: 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: 9/812011 Page 1 of 4 Rev(2/08)