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'-� MONITORING SYSTEM CERTIFICATION •A& For Use By All Jurisdictions Within the State of Calofmi Authority Chapter 6.7, Health and Safety Code; Chapter 16, Divisio le 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 insalled at the facility, a separate certification or report must be prepared for each monitring 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 local agency regulating UST systems within 30 days of test date. Instructions are printed on the back page. A. General Information Facility Name: CHEVRON STATION #208117 Site Address: 755 S. TRACY BLVD Facilty Contact Person: DEALER/MANAGER Make/Model of Monitoring System: TLS 350 B.Inventory of Equipment Tested/Certified City: TRACY Contact Phone No: 000-0000 Date of Testing/Service: 04/30/2001 Word Order Number: 2216530 Check the appropriate boxes to Indicate specific equipment inspected/serviced CA Zip: 95376 Tank ID: 1SUP Model: In -Tank Gauging Probe. Tank ID: 2RE Annular Space or Vault Sensor. Model: 71 In -Tank Gauging Probe. Model: 8374 71 In -Tank Gauging Probe. Model: 8374 -59 Annular Space or Vault Sensor. Model: 409 T Annular Space or Vault Sensor. Model: 409 Piping Sump/Trench Sensor(s). Model: 352 Piping Sump/Trench Sensor(s). Model: 352 Fill Sump Sensor(s). Model: 208 Fill Sump Sensor(s). Model: 208 Mechanical Line Leak Detector. Model: Dispenser Containment Sensor(s). Mechanical Line Leak Detector. Model: Model: Electronic Line Leak Detector. Model: PLLD'39 Electronic Line Leak Detector. Model: PLLD Tank OverfilVHigh-Level Sensor. Model: 8374 Tank Overfill/High-Level Sensor. Model: 8374 Dispenser containment Sensor(s) Model: 208 Dispenser Containment Sensor(s) Model: 208 71 shearvalve(s). Shear Valve(s). Dispenser Containment Float(s) and Chains(s). Dispenser Containment Float(s) and Chains(s). Other(specify equipment type and model in Section E on page 2). Other(specify equipment type and model in Section E on page 2). In -Tank Gauging Probe. Model: In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 7Annular 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: Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s) and Chains(s). Dispenser Containment Float(s) and Chains(s). Other(specify equipment type and model in Section E on page 2). Other(specify equipment type and model in Section E on page 2). C. Certification I cerfify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers guidelines. Attached to this certification is information (e.g manufacturer's 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: MATT COMPANY: Tanknoloqy SIGNATURE: PHONE NO: (800) 800-4633 page 1 of 3 Based on CA form dated 05/00