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d;-®„ y MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of Calofm' Authorit hapter 6.7, Health and Safety Code; Chapter 16, Divis' 23, California 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 insalled at the facility, a separate certification or report must be prepared for each monitring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system owner operator. The owner operator must submit a copy of this form tot a local agency regulating UST systems within 30 days of test date. Instructions are printed on the back page. A. General Information Facility Name: CHEVRON #99840 Site Address: 4344 WATERLOO RD Facilty Contact Person: MANAGER Make/Model of Monitoring System: VEEDER ROOT TLS B.Inventory of Equipment Tested/Certified City: STOCKTON Contact Phone No: 931-2186 Date of Testing/Service: 03/26/2001 Word Order Number: 2216066 Check the appropriate boxes to Indicate specific equipment inspected/serviced CA ZIP: 95210 TanklD: REG Tank ID: SUPER In -Tank Gauging Probe. Model: TLS 71 In -Tank Gauging Probe. Model: 71 Annular Space orvault Sensor. Model: TLS 71 Annular Space or Vault Sensor. Model: TLS Piping Sumprfrench Sensor(s). Model: TLS Piping Sump/Trench Sensor(s). Model: TLS Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: 59 Electronic Line Leak Detector. Model: TLS PLLD Electronic Line Leak Detector, Model: TLS PLLD Tank Overfill/High-Level Sensor. Model: Tank Overfill/High-Level Sensor. Model: Dispenser Containment Sensor(s) Model: TLS Dispenser Containment Sensors) Model: TLS Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s) and Chains(s). Dispenser Containment Float(s) and Chains(s). Other(specify equipment type and model in Section E on page 2). 7 Other(specify equipment type and model in Section E on page 2). lanKu. IaNRIU: In -Tank Gauging Probe. Model: 7 In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 7Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: 7 Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: 7 Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: Tank Overfill/High-Level Sensor. Model: Dispenser Containment Sensor(s). Model: 7 Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: 7 Dispenser Containment Sensor(s). Model: Shear Valve(s). 7 Shear Valve(s). Dispenser Containment Float(s) and Chains(s). Dispenser Containment Float(s) and Chains(s). Other(specify equipment type and model in Section E on page 2). Other(specify equipment type and model in Section E on page 2). C. Certification 1 certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturer's guidelines. Attached to this certification is information (e.g manufacturer's 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, l have also attached a copy of the (Check all that apply): System set-up report; ® Alarm history report PRINTED NAME: ANEIL CHAND SIGNATURE: -..-- COMPANY: Tanknology PHONE NO: (800) 800-4633 page 1 of 3 Based on CA form dated 05/00