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a Appendix V1 1W Rscewo MONITORING SYSTEM CERTIFICATION FEBl 2010 For Use By All Jurisdictions Within the State of California Authority ited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California C ENVIRONMENTHEALTH Regulatio S IT/ E VICES This form mus be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitorir p system control panel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operato . The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General nformation Facility LOWER SAC CHEVRON SiteKI.Bldg. NO.: Site — Adriras v 8660 LOWER SAC City: STOCKTON CA Zip: Facility Contact — --- Parsnn KAMAL — Contact Phone No.: (925) 984.5960 Make/fvodel of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 12/30/2009 B. Inventory of Equipment Tested/Certified Check the a nrnnrinta [ nv t.. i.,.1:....a `---- --______..._.__.-__ Tank ID: 87 OCT Tank ID: 89 OCT ® In -Tank Gaugin 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 Sens r(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical UnE Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line I eak Detector. Model: PLLD ® Electronic Line Leak Detector. Model: PLLD ❑ Tank Overfill / H gh-Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify a uipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: 91 O T Tank ID: ® In -Tank Gauginc Probe. Model: MAG 1 _NA ❑ In -Tank Gauging Probe. Model: ® Annular Space c r Vault Sensor. Model: 407 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump / T ench Sensor(s). Model: 352 ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Senso (s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: —E3 Mechanical Line Leak Detector. Model: ® Electronic Line L aak Detector. Model: TLD ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / Hi]h-Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify ec uipment 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: 5-6 ® Dispenser Conta nment Sensor(s). Model: 322 ® Dispenser Containment Sensor(s). Model: 322 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Conta nment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 3 4 Dispenser ID: 7-8 ® Dispenser Contair,ment Sensor(s). Model: 3220 Dispenser Containment Sensor(s). Model: 322 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Contai iment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment ❑ Dispenser Contai ment Sensor(s). Model: Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Contai ment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). 'If the facility contains more tanks nr rliennne rn.,,, +k;� a -_--- ._. _...._... _...... .....,, ..... .., w... .noNcnoci G t"a lw.,Illty. 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 (pi p int): DAVE WINKLER Certification No.: 263373 -UT _ Testing Company N me: AFFORDAJU Testing Company A dress: 416 2 TR Monitoring SysteH Certification Signature: _ ) License No: 08-1739 _ Phone No. (209) 744-0113 Date of Testing/Servicing: 12-30-2009 Page 1 of 4 2/21/07