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MONIARING SYSTEM CERTIF . ATION 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 This form must be used to document testing and servicing of monitoring equipment. 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 this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: Valley ARCO Bldg. No.: ----------- Site Address: 16 E. Harding Way City: Stockton Zip: 95204 Facility Contact Person: Abraham Contact Phone No.: (209)466-9515 Make/Model of Monitoring System: TLS 350 Date of Testing/Servicing: 04/26/2009 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: Regular Tank ID: Premium x❑ In -Tank Gauging Probe. Model: MAG -1 I] In -Tank Gauging Probe. Model: MAG -1 ❑ Annular Space or Vault Sensor. Model: ❑Annular Space or Vault Sensor. Model: 21 Piping Sump / Trench Sensor(s). Model: 208 ❑x Piping Sump / Trench Sensor(s). Model: 208 ❑x Fill Sump Sensor(s). Model: 208 ❑x Fill Sump Sensor(s). Model: 208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: D Electronic Line Leak Detector. Model: 244-006-5 IRI Electronic Line Leak Detector. Model: 244-006-5 IXI Tank Overfill / High -Level Sensor. Model: TLS -350 0 Tank Overfill / High -Level Sensor. Model: TLS -350 ❑ Other(specify equipment t e and model in Section E on Pae 2). ❑ Other(specify equipment t e and model in Section E on Pae 2). Tank ID: Mid -Grade Tank ID: ❑X In -Tank Gauging Probe. Model: MAG -1 ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: El Piping Sump / Trench Sensor(s). Model: 208 ❑ Piping Sump / Trench Sensor(s). Model: ❑x Fill Sump Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: IHI Electronic Line Leak Detector. Model: 244-006-5 ❑ Electronic Line Leak Detector. Model: 0 Tank Overfill / High -Level Sensor. Model: TLS -350 ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment t e and model in Section E on Page 2). ❑ Other (specify equipment t e and model in Section E on Pae 2). Dispenser ID: 1-2 Dispenser ID: 3-4 ❑ Dispenser Containment Sensor(s). Model: 208 ❑ Dispenser Containment Sensor(s). Model: 208 ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑Dis enser Containment Float(s) and Chain(s). Dispenser ID: 5-6 Dispenser ID: 7-8 ❑ Dispenser Containment Sensor(s). Model: 208 ❑ Dispenser Containment Sensor(s). Model: 208 ❑ 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: ❑ Dispenser Containment Sensor(s). Model: 208 ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Floats 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 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 renorts. I have also attached a cony of the renort: (check all that annlv): R-1 Svstem Technician Name (print): Keith Huston Certification No.: A27755 Testing Company Name: EPIC Compliance Systems, LLC Signature: License. No.: 880430 Phone No.: 888 -700 -EPIC Testing Company Address: 2400 San Bruno Ave, San Francisco, CA Date of Testing/Servicing: 04/29/2009 UN -036 - 1/4 Page I of 4 Rev. 06/04/01 www.unidocs.org