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x MONIAUNG SYSTEM CE TIFI 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 C This form must be used to document testing and servicing of monitoring equipment. A separate certification or retort must be pret�ared o monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank er,( �ator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. L A. General Information ENVi iT L HEALTH Facility Name: Lower Sac Chevron Bldg.No.: Site Address: 8660 Lower Sacramento Rd. City: Stockton,Ca. Zip: 95210 Facility Contact Person: Kamal Contact Phone No.: (209) 477-2844 Make/Model of Monitoring System: Veeder-Root TLS-350 Date of Testing/Servicing: 3/3/2011 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate s ecific equipment ins ted/serviced: Tank ID: T1:91 Tank ID: T2: 89 ❑In-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: Z Annular Space or Vault Sensor. Model: 794390-407 Annular Space or Vault Sensor. Model: 794390-407 Z Piping Sump/Trench Sensor(s). Model: 794380-352 ®Piping Sump/Trench Sensor(s). Model: 794380-352 ❑Fill Sump Sensor(s). Model: ❑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: 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: Z Annular Space or Vault Sensor. Model: 794390-409 ❑Annular Space or Vault Sensor. Model: Z Piping Sump/Trench Sensor(s). Model: 794380-352 ❑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: 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). IL ❑Other(specify equipment type and model in Section E on Page 2). Dispenser ID: 1&2 Dispenser ID: 3&4 Z Dispenser Containment Sensor(s). Model: 794380-322 Z Dispenser Containment Sensor(s). Model: 794380-322 Z Shear Valve(s). Z 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 Z Dispenser Containment Sensor(s). Model: 794380-322 Z Dispenser Containment Sensor(s). Model: 794380-322 Z Shear Valve(s). Z 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 all that apply): ®System set-up ®Alarm history report Technician Name(print): Guadalupe Sanchez Signature:/�e� Certification No.: A30138 License.No.: 883=706 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: 3/3/2011 Page 1 of 4 Rev(2/08)