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MONITORING SYSTEM CERTIFICATION �' w • ',r use By All Jurisdictions Within the State of Califc Adik — Authority Cited. Chapter 6. alth and Safety Code; Chapter W Division 3 Title Wfifornia Code of Regulations This form must be used to document testing and servicing of monitoring equipment. If more than one monitoring system control panel is installed at the facility, a separate certification or report must be prepared for each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system owner. opera or. a owner operator mUSt Submit a copy of t is onn to ffe local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: CHEVRON #99840 Site Address: 4344 WATERLOO RD City: STOCKTON -- CA Zip: 95210 Contact Phone No:931-2186 Date of Testing/Service: 03/14/2002 Facility Contact Person: MANAGER Make/Model of Monitoring System: VR TLS -350 Work Order Number: 2221348 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced Tank ID: SUP Tank ID: RUL In -Tank Gauging Probe. Model: 847380109 71 in -Tank Gauging Probe. Model: 847380-109 Annular Space or Vault Sensor. Model: 794390-407 71 Annular Space or Vault Sensor. Model: 794390-407 Piping Sump/Trench Sensor(s). Model: 794380-352 X 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: Electronic Line Leak Detector. Model: 331196-001 X Electronic Line Leak Detector. Model: 331196-001 Tank Overfill/High-Level Sensor. Model: 61 SO X Tank Overfill/High-Level Sensor. Model: 61 SO Other (specify equipment type and model in Section E on page 2). Other (specify equipment type and model in Section E on page 2). an an In -Tank Gauging Probe. Model: In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: 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. Madel: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: Tank Overfill/High-Level Sensor. Model: Other (specify equipment typ� and model in Section E on page 2). Other (specify equipment type and model in Section E on page 2). L)ISpenser 10. 112 Ispenser ® Dispenser Containment Sensor(s) Model: 794380-208 Dispenser Containment Sensor(s) Model: 794380-208 ® Shear Valye(s). Shear Valve(s) FjDispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser ispenser ® Dispenser Containment Sensor(s) Model: 794380-208 ZIDispenser Containment Sensor(s). Model: 794380-208 ® 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: 11/12 ® Dispenser Containment Sensor(s) Model: 794380-208 71 Dispenser Containment Sensor(s). Model: 794380-208 ® Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). It the taciiny contains more tanK5 Of a1spe11s1:1a, wpy uno wIn. un a�a�c ... ....u.. .. ' .�.... .. _._r_..__. _...._ .__....,. 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 Site Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the (Check all that apply): System set-up report; ® Alarm history report PRINTED NAME:MICHAEL T LEVESQUE COMPANY: Tanknology SIGNATURE: PHONE NO: (800) 800-4633 page 1 of 3 Based on CA form dated 03/01