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Station No. <br />zl3Make <br />.' <br />Model <br />:r <br />any <br />Date <br />i <br />Repaired <br />Station No. <br />zl3Make <br />.' <br />Model <br />lest Date <br />(mm/dd/yy) <br />Test Result <br />Date <br />i <br />Repaired <br />Testrnd Company and Testor <br />Signature <br />Comments <br />(mm/dd/yy) <br />Ta=nks:Ile, <br />Tankievel Monitor (TLM) ` <br />c <br />g <br />1C) -)L4-% <br />Annular Space NLnitor <br />(t <br />Turbine Sump Probe <br />1° <br />ill Sump Probe <br />---------------- <br />Spill Containment Fill Boxes <br />3 <br />Mechanical Overfill PreventionIN1 <br />_2_4%, <br />Remote Overfill <br />Audible and Visual Alarm <br />_1 <br />Electronic Line <br />Pressure Monitor <br />ASS <br />f4 1A <br />Mechanic Leak Detector <br />Dispenser Impact Valve <br />ispenser Sump, Probe <br />l- ILA <br />Emergency Shut-off Switchd <br />t } <br />l <br />Return to M.L. Farrar/Ll 114,P.O. B ox 6004, San Ramon, CA 94583 +, <br />1. Meets 1998 Regulations ❑ Yes ❑ No 4. Test date result and date repaired (if any) must be entered or form will be returned. <br />2. Use comments - as needed. 5. Return to Chevron Office as you complete. <br />3. DO NOT SEND FORM IN BLANK or "DO NOT KNOW" IN SPACES. 6. All forms should be completed by due date Assigned: <br />White and Blue - Chevron Office Ms -97e3 (1-98) <br />Canary -Station Copy: File in Tank Section of Compliance Work Book Word Electronic Version <br />.. <br />