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MON191ORING SYSTEM' YSTE CERTAPATION � � � g + 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 Code of Ira 's This form must be used to document testing and servicing of monitoring equipment. A separate certification or re orrm n monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank, It t 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 Information Facility Name: Wilson Way Chevron Bldg.No.: Site Address: 437 N.Wilson Way City: Stockton, Ca. Zip: 95205 Facility Contact Person: Aman Mehroke Contact Phone No.: (209) 942-2344 Make/Model of Monitoring System: Veeder-Root TLS-350 Date of Testing/Servicing: 2/24/2015 B. Inventory of Equipment Tested/Certified Check the ageropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: T1: 87 Tank ID: T2: 91 ®In-Tank Gauging Probe. Model: 847390-109 ®In-Tank Gauging Probe. Model: 847390-109 ®Annular Space or Vault Sensor. Model: 794390-407 ®Annular Space or Vault Sensor. Model: 794390-407 ®Piping Sump/Trench Sensor(s). Model: 794380-208 ®Piping Sump/Trench Sensor(s). Model: 794380-208 ®Fill Sump Sensor(s). Model: 794380-208 ®Fill Sump Sensor(s). Model: 794380-208 ®Mechanical Line Leak Detector. Model: VMI 99LD-2000 ®Mechanical Line Leak Detector. Model: R.J.FX1V ❑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 type and model in Section E on Page 2). ❑Other(specify equipment type and model in Sect!f?,L,on Page 2). Tank ID: Tank ID: ❑In-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model C., ❑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: El Mechanical Line Leak Detector. Model: $ („ El Electronic Line Leak Detector. Model: E]Electronic Line Leak Detector. Model: 141 ❑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). Dispenser ID: 18,2 Dispenser ID: 3&4 ®Dispenser Containment Sensor(s). Model: 330212-001 ®Dispenser Containment Sensor(s). Model: 330212-001 ®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: 7&8 ®Dispenser Containment Sensor(s). Model: 330212-001 ®Dispenser Containment Sensor(s). Model: 330212-001 ®Shear Valve(s). ®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 Signatures =:::�& Certification No.: A30138 License.No.: 883706 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: 2/24/2015 Page 1 of 4 Rev(2/08)