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Monitoring System Equipment CertiflcDgPEIVED For Use By All Jurisdictions Within The State of California MAY I `� G 0 1 8 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 rEINVIRQMENTAL prepared for each monitoring system control nanel by the technician who performs the work. A copy of this f VENT 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 USA Bldg. No.: Site Address: 755 S. Tracy Blvd City: Tracy, CA Zip: 95376-0000 Facility Contact Person: Manager Contact Phone No.: (209) 830-0370 Make/Model of Monitoring System: VR TLS -350 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Date of Testing/Servicing: 4/10118 Tank ID• 01 -Prem Tank I1Q;02-Regu ❑ In - Tank Gauging Probe. Model: ❑ In - Tank Gauging Probe. Model.- odel:go go Annular Space or Vault Sensor. Model: VR 794390409 ® Annular Space or Vault Sensor. Model: VR 794390.409 ® Piping Sump \ Trench Sensor (s). Model: VR 794390-209 ® Piping Sump \ Trench Sensor (s). Model: VR 794390.209 Fill Sump Sensor (s). Model: VR 794390-209 ® Fill Sump Sensor (s). Model: VR 794380.209 ❑ 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 ❑ Tank Overfill \ High -Level Sensor. Model: I ❑ 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). Tank ID• Tank ID• ❑ 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: ❑ MechanicaI 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 ID- 01-02Dispenser ® Dispenser Containment Sensor (s). Model; VR 794388-208 ID- 03-04 IM Dispenser Containment Sensor (s). Model: VR 7943M208 ❑ Shear Valve (s). ❑ Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser ID• 05-06 Dispenser ID• 07-08 ® 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). 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; ( checks!/ that apply); N System set-up 01 Alarm history report Technician Name (print): Gabriel Padilla Signature: '(j ""' Mfg. Cert.#. 837361 ICC# 8032731 -UT License. No.: 485184 Testing Company Name: Service Station Systems Phone No.: (408) 971-2445 Testing Company Address: 680 Quinn Ave., San Jose, CA 96112 Date of Testing/Servicing: 4/10/18