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. i r Monitoring er i is i 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 system within 30 days of test date. A. General Information Facility Name:Chevron Bldg.No.: Site Address: 6633 Pacific Ave City: Stockton, CA Zip: 95207-3719 Facility Contact Person: Manager Contact Phone No.: (209)4774294 Make/Model of Monitoring System: V/R TLS-350 Date of Testing/Servicing: 12/13/12 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID•01-prem Tank ID• 02-Regu ❑ In-Tank Gauging Probe. Model: VR 847390-107 ❑ In-Tank Gauging Probe. Model: VR 847390.107 Q Annular Space or Vault Sensor. Model: VR 794380301 ❑ Annular Space or Vault Sensor. Model: VR 794380-301 ❑ Piping Sump\Trench Sensor(s). Model: VR 794380-208 ❑ Piping Sump\Trench Sensor(s). Model: VR 794380-208 ❑ FilI Sump Sensor(s). Model: VR 794380-203 19 Fill Sump Sensor(s). Model: VR 794380-208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: VR series 8484 ❑ Electronic Line Leak Detector. Model: VR series 8484 Cl Tank Overfill\High-Level Sensor. Model: ❑ Tank Overfill\High-Level Sensor. Model: Q Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). Tank IQ_• 03-Regu Tank III) ❑ In-Tank Gauging Probe. Model: VR 847390407 ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: VR 794380.301 ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump\Trench Sensor(s). Model: VR 794380-208 ❑ Piping Sump\Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: VR 794380-208 ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: VR series 8484 ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill\High-Level Sensor. Model: ❑ Tank Overfill\High-Level Sensor. Model: Q 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- 01-02 Dispenser ID• 03-04 ❑ Dispenser Containment Sensor(s). Model: VR 794380-208 ❑ Dispenser Containment Sensor(s). Model: VR 794380-208 ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). FDer ID- 05-06 Dispenser ID: 07-08 er Containment Sensor(s). Model: VR 794380-208 ❑ Dispenser Containment Sensor(s). Model: YR 794380 208 alve(s). ❑ Shear Valve(s). er Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 09-10 Dispenser ID• 11-12 ❑ Dispenser Containment Sensor(s). Model: VR 794380-208 ❑ Dispenser Containment Sensor(s), Model: VR 794380-208 ❑ 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 manufacturer's guidelines. Attached to this Certification is information(e.g.manufactures'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; (check all that apply): System set-up IN Alarm history report Technician Name(print): Myke Briggs Signature: 1#14 m Mfg.Cert.#.: B38235 ICC# 8033115-UT License.No.: 485184 Testing Company Name: Service Station Systems Phone No.: (408)971-2445 ` Testing Company Address: 680 Quinn Ave.,San Jose, CA 95112 Date of Testing/Servicing: 12/13/12