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03/23/2015 5:44AM FAX 19252 0 71 Guadalupe Sanchez 0 IM0001/0010 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Aulhority Cited;Chapter 6.7, Health and Safety Code,Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing o)'tM�i't �q}tiptrtent.A se cc r wn r he rc ared or each muni tiring sy ni control Martel by the technician who perfo -this Pia t vl system owner/operator. The owner/operator must'submit a copy of this form to the 1 i ems within 3(i days of test e. A. General Information A2 2015 I Facility Name: Wilson Wa Chevron Na.: Site Address; 437 N.Wilson Way1 .M95205 Facility Contact Person: Aman Mehrroke ntact Phone No.: (209) 942-2344 Make/Model of Monitoring System: Veeder-Root TLS-360 Date of Testing/Servicing: 2/24/2015 B. Inventory of Equipment Tested/Certified 9-17A Check theappropriate boxes to Indicates eeiric, ul ment ins eted/serviced: Tank ID. T1.87 . Tank ID; T2:91 ®In-'rank Gauging Probe. Modci; 847390-109 M In-Tank Gauging Probe. Model! 847390-109 M Annular Space or Vault Sensor. Model: 794390-407 ®Annular Space or Vault Sensor, Model; T-390-407 ®Piping Sump Priencli Sensor(s). Model: 794380-208 _ Piping Sump Trench Sensor(s), Model: 784380-208 ®Fill Sump Sensor(s). Model; 794380-208 M Fill Sump Sensor(s). Model: 794380-208 LEr-31 echanical Line Lcak Detector, Model; VMI 991-13-2000 ®Mechanical Line Leak Gctcctar. Madel; R.J.FX1V lectronic bine Leak Detector. Model. 0 Electronic Linc Lcak Detector, Model; ank Overfill/High-Level Scnsor. Modci: ❑Tank Overfill!High-Level Sensor. Model: ther{specify equipment type and model in Section E on Page 2). ❑Other(specify equipment type and model in Section E on Page 2). Tank ID: Tank ID: ❑In-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: ❑Annular Spacc or Vault Sensor, Model; ❑Annular Space or Vault Sensor. Model: _ ❑Piping Sump/Trench Sensor(s), Model; ❑Piping Sump!Trench Sensor(s). Model; ❑Fill Sump Scnsor(s). Model: ❑Pili Sump Sensor(s). Model: -- ❑Mechanical Line Leak Detector. Model: _ ❑Mechanical Line Leak Detector. Model: ❑>icaronic Linc Leak Detector, ModcL• ❑Eleclmnic Linc Leak Detcotor. Model.- Tank Overfill/High-Level Sensor. Model; _ ❑Tank Overfill/High-Level Sensor. MuticL ❑Other(specify equipment type and model in Section H on Page 2). ❑Others equipment (s I�fY type and model in Section C on Page 2). Dispenser ID: 1&2 Dispenser ID: 3&4 M Dispenser Containment Scnsor(s). Model: 330212.001 Dispenser Containment Sensor(s). .Model: 330212-001 ®Shear Valvc(s), ®Shear Valvc(s). ❑Dispenser Containment Float(s)and Chain(s), ❑Dispenser CunWnmcnt Floats)and Chain(%). [Dispenser ID: 5&6 Dispenser ID- 7&8 Dispenser Containment Sensor(s). Model: 330212-001 ®17ispcnser Containment Sensor(s). Model: 330212.001 M Shear Valvc(s). 19 Shear Valve(s). ❑Dispenser Containment Flout(s)and Chain(s). ❑Dispenser Containment Floats)and Chain(s). Dispenser ED: Dispenser ID: ❑Dispenser Containment Sensor(s). Memel; ❑Dispenser(containment Sensor(s). Mudcl; ❑Shear Valve(s). ❑$hear Valve(%). — . ❑Dispenser Containment Float(%)and Chain(%). ❑Dispenser Containment Nioat(s)and C:hain(s). *If the facility contains rnorC tanks or dispensers,copy this form. Includ8 information for every tank atld dispenser rtt the facility. C. Certifleation-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 or the report;(check all that apply): ® System set-up ®Alarm history report Technician Name(print); Guadalupe Sanchez Signature: Certification No.: A30139 License.No.: 883706 Testing Company Narne: Reliable Petroleum Services,Inc. Phone No.: 209 846-8586 Testing Company Address: 11930 Horseshoe Rd.Oakdale,Ca.96361 Date of Tcsting(Servicing: 2/24/2016 Page 1 of 4 Rev(2/08)