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MONITORING SYSTEM CERTIFICATION For Use By All Jurls&ctions Authority Cited:Chapter 6.7, Health and Safety Code; Chapter h16,in 1Divishe ion 3, Title 23,te of 1 California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or ulreport w prepared for each monitoring t trol oanel 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: Fast Lane (Lathrop) Site Address: 116 East Roth Road Bldg.No. — Facility Contact Person: Hardeep Gill City: Lathrop Zip: 95330 Make/Model of Monitoring System: Veeder Root TLS-350 Contact Phone No: 707-326-0369 B. Inventory of Equipment Tested/Certified Date of Testing/Servicing: 7/30/2012 Check lbeaurniuriate boxes to indicates ecit-ice ui ment inspected/serviced: Tank lD: 1 - Diesel South LID: nk Gauging Probe. Model: T lar Space or Vault Sensor. Model: 13 k Gauging Probe. Model: ar Space or Vault Sensor. Modelg Sump/Trench Sensor(,). Model: 208 (— Sump/Trench Sensor(s). Model:_ump Sensor(,). Model:anical Line Leak Detector. Model: mp Sensor(,). Model-onic Line Leak Detector. Model.— El nical Line Leak Detector. ModelOverfill/High-Level Sensor. Model:= nic Line Leak Detector. Model(s ci a uimen[ and model in Section E on Pa 2). ❑ Other13 (specify Overfill High-Level mtSensor. and e�SeMion E : 2 - Diesel North 9 P g ) ❑ in-Tank Gauging Probe. Model: TankID: ❑ Annular Space or Vault Sensor. Model:= G -Tank Gauging Probe. Model: Piping Sump/Trench Sensor(s). Model:_ 208 (L3) O Annular Space or Vault Sensor. Model:= ❑ Fill Sump Sensor(s). Q Piping Sump/Trench Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model:—� Ll Fill Sump Sensor(,). 13Mechanical Line Leak Detector. Model:= O Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model:= G Electronic Line Leak Detector. Model: _— rD' ci a ui ment G Tank Overfill/High-Level Sensor. del el— and model in Section E on Pae 2 . El Other(specify equipment type and model in Section E on Page 2). D: 13 r Containment Sensor(,). Model: 208 (L13) Dispenser ID: 16 lve(s). Dispenser Containment Sensor(,). Model: 208 (L19) --- "peas Containment Float(s)and Chain(s). 13 Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 14 ® Dispenser Containment Sensor(s). Model: 208 (L15) DispenserlD: 17 L3 Shea Valve(,). ® Dispenser Containment Sensor(,). Model: 208 (L21) LJDispenser Containment Floats and Chain(,). O Shear Valve(s). ❑ Dispenser Containment Float(,)and Chain(s). Dispenser er 15 Dispenser ID: 18 Dispenser Containment Sensor(,). Model: _208 (L17) ®Dispenser Containment Sensor(,). Model: 208 (L23) ❑ Shear Valve(,). ❑ Shear Valve(s). ❑ Dis nser Containment Float(, and Chain(s). LIDis nser Containment Float(, and Chains . *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): O System set-up ❑x Alarm history report Technician Name(print): Al Milburn Signature: Certification No: A27843 License No. 956593 Testing Company Name: EPIC Compliance Systems Inc. Phone No. 888-700-EPIC Testing Company Address:_1435 Huntington Ave Suite 230 UN-036-1/4 Page South San Francisco CA9Page Date of Testing/Servicing: 7/30/2012 1 of 4 Rev.06/04/01 www.unidocs.org