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VjiLDMONITORING SYSTEM CERTIFICATION MAY 2 ! 2/C For Use By All Jurisdictions Within the State of California EIV Rr�,;....,-, .. Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, Californ►p tie �Rt�h& sTH F'tti V-11 i/JERVICS This form must be used to document testing and servicing of monitoring equipment. A separate certification or repo 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, CA zip: 95204 Facility Contact Person: Paul Contact Phone No.: (209) 606-3551 Make/Model of Monitoring System: VEEDER ROOT TLS -350 Date of Testing/Servicing: 05/07/08 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/seryiced: TanklD: 1-87 Tank ID: 3-89 ❑O In -Tank Gauging Probe. Model: MAG -1 El In -Tank Gauging Probe. Model: MAG -1 © Annular Space or Vault Sensor. Model: 794380-420 ❑x Annular Space or Vault Sensor. Model: 794380-420 El Piping Sump / Trench Sensor(s). Model: 794380-208 ❑x Piping Sump / Trench Sensor(s). Model: 794380-208 O Fill Sump Sensor(s). Model: 794380-208 M Fill Sump Sensor(s). Model: 794380-208 ❑ 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 Pae 2). ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: 2 — 91 Tank ID: ❑O In -Tank Gauging Probe. Model: MAG -1 ❑ In -Tank Gauging Probe. Model: ❑O Annular Space or Vault Sensor. Model: 794380-420 ❑ Annular Space or Vault Sensor. Model: ❑x Piping Sump / Trench Sensor(s). Model: 794380-208 ❑ Piping Sump / Trench Sensor(s). Model: ❑x Fill Sump Sensor(s). Model: 794380-208 ❑ 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 ID: 1-2 Dispenser ID: 7-8 ❑x Dispenser Containment Sensor(s). Model: 794380-208 M Dispenser Containment Sensor(s). Model: 794380-208 ❑x Shear Valve(s). ❑O Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 3-4 Dispenser ID: 9-10 ❑O Dispenser Containment Sensor(s). Model: 794380-208 ❑x Dispenser Containment Sensor(s). Model: 794380-208 Il Shear Valve(s). O Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5-6 Dispenser ID: O Dispenser Containment Sensor(s). Model: 794380-208 ❑ Dispenser Containment Sensor(s). Model: ❑X Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats 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 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): El System set-up ❑O Alarm history report Technician Name (print): Alvin L. Milburn Signature: �%_ V1�- Certification No.: A27843 Testing Company Name: EPIC Compliance Systems, Inc. Testing Company Address: 2400 San Bruno Ave, San Francisco, CA UN -036 -1/4 Page 1 of 4 www.unidoes.org License. No.: 880430 Phone No.: 888 -777 -EPIC Date of Testing/Servicing: 05/07/08 Rev. 06/04/01