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MONITORING SYSTEM CERTIFICATION Use By All Jurisdictions Within the State of Califo Authority Cited. Chapter 6.70lth 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. 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 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 t tis orm tot a local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: CHEVRON #208117 Site Address: 755 S. TRACY BLVD @ SCHULTE RD Facility Contact Person: MGR - MARIA Make/Model of Monitoring System: TLS350 B. Inventory of Equipment Tested/Certified City: TRACY Contact Phone No: 830-0370 Date of Testing/Service: 04/16/2002 Work Order Number: 2221890 Check the appropriate boxes to indicate specific equipment inspected/serviced CA Zip: 95376 Tank ID: SUPER Tank ID: RUL In -Tank Gauging Probe. Model: MAGI In -Tank Gauging Probe. Model: MAG1 71 Annular Space or Vault Sensor. Model: 794390409 71 Annular Space or Vault Sensor. Model: 794390409 71 Piping Sump/Trench Sensor(s). Model: 794380352 X Piping Sump/Trench Sensor(s). Model: 794380352 Fill Sump Sensor(s). Model: 794380208 X794380208 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: 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)• 1 Other (specify equipment type and model in Section E on page 2). an an In -Tank Gauging Probe. Model: in -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: Piping Sump/Trench 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 10: j1z ispenser ® Dispenser Containment Sensor(s) Model: 794380208 Dispenser Containment Sensor(s) Model: 794380208 ❑ Shear Valve(s). Shear Valves) ❑ Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). DispenserUispenserlD: 911U ® Dispenser Containment Sensor(s) Model: 794380208 Dispenser Containment Sensor(s). Model: 794380208 ❑ Shear Valve(s). Shear VaNe(s). Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5/6 DispenserlD: 11/12 © Dispenser Containment Sensor(s) Model: 794380208 Dispenser Containment Sensor(s). Model: 794380208 Shear Valve(s). Shear Valve(s). 10 Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). x It the facility contains more tanks or dispensers, copy this torm. Include information Tor 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 Pq PRINTED NAME: DAVID MATHIE SIGNATURE: COMPANY: Tanknology PHONE NO: (800) 800-4633 page 1 of 3 Based on CA form dated 03/01