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t ,'Pp Tanknok3gy MONITORING SYSTEM CERTIFICATION se By All Jurisdictions Within the State of Califom Authority Cited.Chapter 6.7,Health and Safety Code;Chapter 16,Division 3 Title 23, alifornia 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 installed at the facility,a separate certification or report must be prepared for each monitoring system control oanel 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 209167 City: MANTECA CA Zip:95336 Site Address: 1234 YOSEMITE AVE Contact Phone No:824-7433 Facility Contact Person: MANAGER-KIM Date of Testing/Service: 06/23/2003 Make/Model of Monitoring System: TLS 350 Work Order Number: 2226679 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced Tank ID: UNLEADED Tank ID: SUPREME X In-Tank Gauging Probe. Model: MAG X In-Tank Gauging Probe. Model: MAG X Annular Space or Vault Sensor. Model: 409 Annular Space or Vault Sensor. Model: 409 X Piping Sumpffrench Sensor(s). Model: mv Piping Sumpfrrench Sensor(s). Model: 208 Fill Sump Sensor(s). Model: ED Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: PLLDX Electronic Line Leak Detector. Model: PLLD 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). TankiD: TanklD: In-Tank Gauging Probe. Model: In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: Piping Sumpffrench Sensor(s). Model: Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: 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: 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 : 1/2 Dispenser ID: 7/8 ®Dispenser containment Sensor(s) Model:208 X Dispenser Containment Sensor(s) Model:208 XD Shear Valve(s). X Shear Valve(s) Dispenser Containment Float(s)and Chain(s). 7 Dispenser Containment Float(s)and Chain(s). Dispenser ID: 3/4 Dispenser ID: 9/10 X❑ Dispenser Containment Sensor(s) Model:208 Dispenser Containment Sensor(s). Model:208 M Shear Valve(s). Shear Valve(s). ElDispenser Containment Float(s)and Chain(s). 7 Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5/6 Dispenser ID: 11/12 ® Dispenser Containment Sensor(s) Model:208 X Dispenser Containment Sensor(s). Model:208 ❑X Shear Valve(s). X Shear Valve(s). Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). 10 *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 Site Plan showing the layout of monitoring equipment.For any equipment capable of generating such reports,I have also attached a copy of the(Check all that apply): System set-up report; ❑ Alarm history report PRINTED NAME:KEVIN MATLOCK SIGNATURE: COMPANY: Tanknology PHONE NO: (800)800-4633 page 1 of 3 Based on CA form dated 03/01