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MONIT NG SYSTEM CERTIF100TIOIRECEIVED a 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 ofRegulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report m Be Map lAr each monitoring system control panel by the technician who performs the work. A copy of this form must be provided tostem owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of tes HEALTHailONMENTAL A. General Information Facility Name: CHEVRON Site Address: 4415 PACIFIC AVE. Facility Contact Person: TAMMY Make/Model of Monitoring System: VEEDER ROOT TLS 350 B. Inventory of Equipment Tested/Certified City: STOCKTON Contact Phone No.: (209 Bldg. No.: _ Zip: 95202 473-0204 Date of Testing/Servicing: 12/2/2013 Check thea ro riare oozes to mmcaM c u. ...c.0 ..., ID: #1 87 REGULAR Tank ID: #2 PREMIUM Tank Gauging Probe. Fing Model: ❑ In -Tank Gauging Probe. Model: nular Space or Vault Sensor. Model: 794380-420 ❑ Annular Space or Vault Sensor. Model: Sump / Trench Sensor(s). Model: 794380-208 ® Piping Sump / Trench Sensor(s). Model: 794380-208 ❑ 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: [3 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). 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: I ❑ 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. [3� 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: # 1-2 Dispenser ID: # 3-4 Z Dispenser Containment Sensor(s). Model: 794380-323 ® Dispenser Containment Sensor(s). Model: 794380-323 ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: #5-6 Dispenser ID: #7-8 Z Dispenser Containment Sensor(s). Model: 794380-323 ® Dispenser Containment Sensor(s). Model: 794380-323 ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: #9-10 Dispenser ID: #11-12 Z Dispenser Containment Sensor(s). Model: 794380-208 Z Dispenser Containment Sensor(s). Model: 794380-208 ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). _i. _a a:, ..t tt,o f ..;Nt.� *If the facility contains more tanks or dispensers, copy this form. include information for every tarn auu UMFY Ilaw — u.., i....=._.,. 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 Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the report; (check all that apply): Z System set-up arm history repo iC Technician Name (print): ERIC SCHELL Signature: !`®rt; firatinn Nn s2snsRn_UT License. No.: 491948 Testing Company Name: CENTRAL PETROLEUM Testing Company Address: 176 WYOMING ST. PLEASANTON , CA. Page 1 of 3 Phone No.: (925) 462-4060 Date of Testing/Servicing: 12/2/2013 UN -036 —1/4 www.unidocs.org Rev. 01/17/08