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Appendix VI (Copies of Monitodng System Certification form and UST Monitoring Plot Plan available at httr):/lwww.waterboards.ca.gov.) MONITORING SYSTEM CERTIFICATION 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 ownerioperator 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 GIII Contact Phone No.: 707-326-0369 Make/Model of Monitoring System: VR 350 Date of Testing/Servicing: 6/19/2017 B.Inventory of Equipment Tested/Certified Auto Side Check the appropriate boxes to indicatespecific a ui ment ins ectediserviced: Tank ID: T1 87 Tank ID: T3 Diesel ?, In-Tank Gauging Probe. Model: - In-Tank Gauging Probe. Model: - lz. Annuiar Space or Vault Sensor. Model: 303 v Annular Space or Vault Sensor. Model: 303 v Piping Sump 1 Trench Sensor(s), Model: 208 , Piping Sump i Trench Sensor(s). Model: 208 Ir Fill Sump Sensor(s). Model: 208 n Fill Sump Sensor(s). Model 208 Mechanical Line Leak Detector. Model: 99LD2000 71 Mechanical Line Leak Detector. Model: 99LD2000 Electronic Line Leak Detector. Model: -I Electronic Line Leak Detector. Model: Tank Overfill 1 High-Level Sensor. Model: Tank Overfill 1 High-Level Sensor, Model: Other(specifym a ui ent a and model in Section E on Pa e 2 Others eci a ui ment type and model in Section E on Page 2 Tank ID: T2 91 Tank ID: In-Tank Gauging Probe. Model: MAG-7 In-Tank Gauging Probe. Model: ,i Annular Space or Vault Sensor. Model: 303 C Annular Space or Vault Sensor, Model: P Piping Sump I Trench Sensor(s). Model: 208 l= Piping Sump/Trench Sensor(s). Model: V Fill Sump Sensor(s). Model: 208 Fill Sump Sensor(s). Madel: Mechanical Line Leak Detector. Model: 99LD2000 Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill 1 High-Level Sensor. Model: 7 Tank Overfill l High-Level Sensor. Model: Other(specify equipment t e and model in Section L on Page 2). I Other(specify equipment t e and model in Section F on Page 2). -4 Dispenser ID: 1/2 Dispenser ID: 7/8 • Dispenser Containment Sensor(s). Mcdel: 208 i Dispenser Containment Sensor(s). Model: 208 • Shear Valve(s). t Shear Valve(s). b6W _� Dispenser Containment Floats and Chain(s). Dispenser Containment Floats and Chains. Dispenser ID: 3/4 Dispenser ID: 9/10 Dispenser Containment Sensor(s). Model: 208 Dispenser Containment Sensor(s). Model: 208 U C Shear Valve(s). Shear Valve(s), Dispenser Containment Floats and Chain(s). Dispenser Containment Floats and Chain(s).. Dispenser ID: 5/6 Dispenser ID: 11/12 2 Dispenser Containment Sensor(s). Model 208 r Dispenser Containment Sensor(s). Model: 208 I Shear Valve(s). Fv Shear Valve(s). n Dispenser Containment Floats and Chain(s). E 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 reports,I have also attached a copy of the report;(check all that apply): I System set-up Alarm history report Technician Name(print): Brian Dunclhay Signature: Certification No.: 642886 License.No.: 956593 Testing Company Name: EPIC Environmental Corry liance Systems Inc. Phone No.: 888-700-EPIC Testing Company Address: 39120 Argonaut Way # 643, Fremont, CA 94538 Date of Testing/Servicing: 6/19/2017 Monitoring System Certification Page 1 of 4 12107 1 2121107