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06/15/2004 11:45 12093653 TANKNOLOGY 40 PAGE 08 OtInrireVV>O�a�,-_ wrp� ONiTORING 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 Tttia form must be used to document testing and servicing of monitoring equipment. If more than one monitoring system control panel is Installed at the faculty, a separate certtcation or re0ort must be prepared for each monitodrie 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 last date, A. General Information Facility Name: CHEVRON #208117 Site Address; 755 S. TRACY BLVD Facility Contact Person: _MGR - MARIA Make/Model of Monitoring System; TLS -350 Work Order Number, 2230343 B. Inventory of Equipment Tested/Certified City: TRACY Contact Phone No: 830-0370 Date of Testing/Service: 03/24/2004 Check the appropriate boxes to indicate specific equipment Inspected/Serviced CA Zip: 95376 Tank ID: 1,91 Tank ID: 2-87 71 In -Tank Gauging Probe, Model: MAG X In -Tank Gauging Probe. Model: MAG X Annular Space or Vault Sensor. Model; QL_ Annular Space or Vault Sensor. Model: 409 X Piping Sumprrrench Sensor(s), Model: 352 - Piping Sumprrrench Sensor(e), Modal: 352 X Fill Sump Sensor(s), Model: _ _ Fill Sump Sensor(s), Model: 208 Metchaniml Llne Leak Detector. Model: El Electronic Une Leak Detector. Model PLLD Mechanical lJne Leak Detector. X Electronic Line Leak Detector. Model: Model: PLLD Tank Overfill/High-Level Sensor, Model: _ _ Tank Overfiu(Migh-Level Sensor, Model: Other (specify equipment type and model in Section E on page 2). Other (specify equipment type and motlel in 5ecGon E onp page 2), Tank ID: Tank ID: In -Tank Gauging Probe. Model: In -Tank Gauging Probe. Model: Annular Space or Vault Sentior. Model: Annular Space or Vault Sensor, Model: Piping SUmprrrench Sensor(s), Model: Piping Sumprfrench Sensor(s), Model; Pill Sump Sensor(e). Model: Fill Sump Sensor(s), Model; Mechanical Llne Leak Detector. Model; Mechanical Lin® Leak Detector. Modell; Electronic Una Leak Detector. Model; Electronic Line Leak Detector. Model: Overfill/High-Level Sensor, Modal: Tank Overfill/High-Level Sensor, Model: Other (specify equipment type and model in Section S on page 2). Other (specify equipment type and motel in Section E on page 2), rspenser : 1LZ Dispenser ID: 314 X Dispenser Containment Sensor(s) Model: 208 XCj Dispenser Containment Sensor(s) Model: 208 Shear Valve(s). X Shear Valves) Dispenser Containment Roat(s) and Chaln(s), Dispenser Containment Floats) and Chaln(s), Dispenser ID: 516 Dispenser ID: 7/8 D Disponsee Containment Sensor(s) Model: 208 Olsponssr Containment Sensor(s). Model: 208 Show Velve(s). Shear Valve(s). Dispenser Containment Ftoat(s) and Chaln(s). Dispenser Containment Float(g) and Chain(s), DispenserID: 9/10 Dispenser 10; 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(t) and Chain(s), U Dispenser Containment Floet(e) and Chain(s). - It 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/serAced 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 crf generating such reports, I have also attached a copy of the (Check all that apply): System set-up report; ❑ Alarm history report X❑ PRINTED NAME:DOUGL,AS HARTY SIGNATURE: COMPANY: Tanknoloax PHONE N0; 800 600-4633 page 1 of 3 Based on CA form dated 03/01