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'ii 1II Appendix VI ( " (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.waterboards.ca.gov.) MONITORING SYSTEM CERTIFICATION AUG 14 2017 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 ownerloperator. 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: Fast Lane Central Valley Bldg.No.: Site Address: 116 East Roth Rd city; Lathrop, CA zip: 95330 Facility Contact Person: Hardeep Gill Contact Phone No.. 707-326-0369 MakelModel of Monitoring System: VR 350 Date of Testing/Servicing: 6/20/2017 B. Inventory of Equipment Tested/Certified Truck side Check the appropriate boxes to indicate specific equipment ins ectedlserviced: B T1 Diesel South Tank ID: nk Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: lar Space or Vault Sensor. Mode{: 303 ❑ Annular Space or Vault Sensor. Model: Sump/Trench Senscr(s). Model: 208 ❑ Piping Sump!Trench Sensor(s). Model:mp Sensor(s). Model 208 ❑ Fill Sump Sensor(s). Model: anical Line Leak Detector. Model 99LD2000 l Mechanical Line Leak Detector, Model: ronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Overfill 1 High-Level Sensor. Model: ❑ Tank Overfill 1 High-Level Sensor. Model: s eci equipment a and model in Section E on Page 2). ❑ Other (sped equipment t e and model in Section E an Page 2). Tank ID: T2 Diesel North Tank ID: 1 In-Tank Gauging Probe. Model: MAG-7 - In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: 303 -1 Annular Space or Vault Sensor. Model: Piping Sump 1 Trench Sensor(s). Model: 208 Piping Sump 1 Trench Sensor(s). Model: Fill Sump Sensor(s). MOdel: 208 Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model 99LD2000 I Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Lire Leak Detector. Model: Tank Overfill 1 High-Level Sensor. Model: I Tank Overfill 1 High-Level Sensor. Model: Other(specify e ui ment type and model in Section E on Page 2). 1 I Others eci equipment t e and model in Section E on Page 2). Dispenser ID: 13 Dispenser ID: 16 +I Dispenser Containment Sensor(s). Model: 203 = Dispenser Containment Sensor(s). Model 208 �I Shear Valve(s). _ Shear Valve(s). I Dispenser Containment Floats and Chains. Dis enser Containment Floats and Chain(s). Dispenser ID: 14 Dispenser 1D: 17 Dispenser Containment Sensor(s). Model: 2O8 Lr Dispenser Containment Sensor(s). Model: 208 til Shear Valve(s). Le Shear Valve(s). ft Dispenser Containment Flcat s and Chains. ❑ Dispenser Containment Floats and Chains. Dispenser ID: 15 Dispenser ID: 18 1r Dispenser Containment Sensor(s). Model: 208 a Dispenser Containment Sensor(s). Model: 208 E� Shear Valve(s). ii Shear Valve(s). 7 Dispenser Containment Floats and Chain(s). Dispenser Containment Floats and Chains. *If the facility contains more tanks or dispensers,copy this form. Include information for every tankard dispenser at the facility. C. Certification - I certify that the equipment identified in this document was inspectedlserviced in accordance with the manufacturers' Sd lyt`� guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct 9_ and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attached a it Ci copy of the report;(check all that apply): System set-up FI Alarm history report 1 ` Technician Name(print): Briar) Dunahay Signature: Certification No.: B42886 License.No.: 956593 Testing Company Name: EPIC Environmental Compliance Systems Inc. Phone No.: 888-700-EPIC Testing Company Address: 39120 Argonaut Way # 643, Fremont, CA 94538 Date of TestinglServicing: 6/20/2017 Monitoring System Certification Page 1 of 4 12107 2/21/07