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r NOV 0 2 2016 Appendix Vii ENVIRONMENTAL HEALTH (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http:lwww.waterbnatdsca 11 A MONITORING SYSTEM CERTIFICATION wl For Use By All Jurisdictions Within the State of Califomia 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: East Lane Central Valley (Truck Side) Bldg.No.: — Site Address: 116 E Roth Rd city. Lathrop, CA zip: 95330 Facility Contact Person: Hardeep Gill Contact Phone No.: 707-326-0369 Make/Model of Monitoring System: VR — 350 Date of Testing/Servicing: 8/8/2016 B, Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment ins ectedlserviced: FID: Diesel South Tank ID: ging Probe. Model: MAG-7 In-Tank Gauging Probe. Model: ce or Vauft Sensor. Model: Annular Space or Vault Sensor. Model: 1 Trench Sensor(s). Model: Piping Sump i Trench Sensor(s). Model: C Fill Sump Sensor(s). Model: a Fill Sump Sensor(s). Model: Mechanical(Line Leak Detector, Model: I Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: i Electronic Line Leak Detector. Model: Tank Overfill 1 High-Level Sensor. Model I Tank Overfill i High-Level Sensor. Model: A Other(specify equipment t e and model in Section E on Page 2). Other(specify equiloment type and model in Section F on Page 2). Tank 11 2 — Diesel North Tank ID: 10 In-Tank Gauging Probe. Model: MAG-7 In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: Piping Sump 1 Trench Sensor(s). Model: Piping Sump 1 Trench Sensor(s). Model: Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: I Mechanical Line Leak Detector. Model: I Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: r Tank Overfill 1 High-Level Sensor. Model: Tank Overfill 1 High-Level Sensor. Model: 201 Other(specify equipment t e and model in Section E on Pae 2). Other(specify equipment t e and model in Section Dispenser ID: 13 Dispenser ID:1C Dispenser Containment Sensor(s). Model, Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). i Dispenser Containment Floats and Chains. Dispenser Containment Float(s)and Chains. Dispenser ID: 14 Dispenser ID: 17 L Dispenser Containment Sensor(s). Model: Dispenser Containment Senser(s), Model: Shear Valve(s), I Shear Valve(s). Dispenser Containment Floats and Chains. ❑ Dis enser Containment Floats and Chains. Dispenser ID: 15 Dispenser ID: 18 Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). i Dispenser Containment Floats and Chains i 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 inspectedlserviced 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): System set-up I Alarm history report ] Technician Name(print): Alvin L. Milburn Signature: Certification No.: A27843 License.No.: 956593 Testing Company Name: EPIC Environmental Compliance Systems Inc. Phone No.: 888700-EPIC Testing Company Address: 39120 Argonaut Way # 643, Fremont, CA 94538 Date of Testing/Servicing: 8/8/2016 Monitoring System Certification Page 1 of 4 12J07 1 2121107