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(Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.swrcb.ca.gov.) MONITORING SYSTEM CERTIFICATION 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 Regulations This form must be used to document testing and servicing of monitoring equipment. 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/operator. 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: CHEVRON 208118 N-4087-1-3 Bldg. No.: 208118 Site Address: 3355 E. HAMMER LANE@ HOLMAN RD City: STOCKTON Zip: 95212 Facility Contact Person: MANAGER Contact Phone No.: 477-3699 Make/Model of Monitoring System: Veeder Root TLS -350 Date of Testing/Servicing: 2/23/2012 B. Inventory of Equipment Tested/Certified Check the annrnnriatP hnxec to indicate cnPri£r Pnninment inenPrtad /cPrvir de Tank ID: T1: -SUPREME Tank ID: T2: - REGULAR [v In -Tank Gauging Probe. Model: MAG ✓ In -Tank Gauging Probe. Model: MAG ry Annular Space or Vault Sensor. Model: 409 r Annular Space or Vault Sensor. Model: 409 ry Piping Sump / Trench Sensor(s). Model: 208 W Piping Sump / Trench Sensor(s). Model: 208 r— Fill Sump Sensor(s). Model: r Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: r Mechanical Line Leak Detector. Model: ry Electronic Line Leak Detector. Model: Veeder Root PLLD r' Electronic Line Leak Detector. Model: Veeder Root PLLD rV Tank Overfill / High -Level Sensor. Model: FLAPPER: Tank Overfill / High -Level Sensor. Model: FLAPPER Other(specify equipment a and model in Section E on Pae 2). r Other(specify equipment a and model in Section E on Pae 2). Tank ID: Tank ID: In -Tank Gauging Probe. Model: In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: r Annular Space or Vault Sensor. Model: F Piping Sump / Trench Sensor(s). Model: Piping Sump / Trench Sensor(s). Model: Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: r Mechanical Line Leak Detector. Model: r Mechanical Line Leak Detector. Model: r Electronic Line Leak Detector. Model: r Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: ( Tank Overfill / High -Level Sensor. Model: Other(specify equipment a and model in Section E on Pae 2). r Other(specify equipment a and model in Section E on Pae 2). Dispenser 1/2 Dispenser 3/4 ID: ID: Dispenser Containment Sensor(s). Model: 208 W Dispenser Containment Sensor(s). Model: 208 rV Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s) and Chain(s). r7 Dispenser Containment Float(s) and Chain(s). Dispenser 5/6 Dispenser 7/8 ID: ID: Dispenser Containment Sensor(s). Model: 208 Dispenser Containment Sensor(s). Model: 208 WO Shear Valve(s). rV Shear Valve(s). r. Dispenser Containment Float(s) and Chain(s). r Dispenser Containment Float(s) and Chain(s). Dispenser 9/10 Dispenser 11/12 ID: ID: Dispenser Containment Sensor(s). Model: 208 rV Dispenser Containment Sensor(s). Model: 208 W Shear Valve(s). rV Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). -u me Tacmty contains more tanKs or dispensers, copy tris corm. ►ncivae inrormation tor every tank ano aispenser at the racility. 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): r— System set- up rvo Alarm history report Technician Name (print): Certification No.: 83674: Steven Willems Testing Company Name: Tanknology Signature: License. No.: 743160 Class 'A' Phone No.: (800) 800-4633 Testing Company Address: 11000 N. MoPac Expressway Suite 500 Date of Testing/Servicing: 2/23/2012 Monitoring System Certification Page i of 3 12/07