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MONI,4RING SYSTEM CERTIF&TION For Use By All Jurisdictions Within the State of California Regulations Authority Cited: Chapter 6.7,Health and Safety Code; Chapter 16, Division 3, Title 23, California Code oforr ui ment. A separate certification or re ort must be y eg equi the work. A copy of this form must be provided to This form must be used to document testing and servicing of monitoring equipment. of this form to the local agency regulating UST systems prepared for each monitoring s stem control opel b the technician w o p the tank system owner/operator. The owner/operator must submit a copy within 30 days of test date. A. General information Bldg.No. Facility Name- Fast Lane-Lathrop (Truck Side) P' zi 95330 City: Lathrop, CA Site Address: 116 E Roth Road Contact Phone No: 707-326-0369 Facility Contact Person: Hardee p Gill 5/23/2011 Date of Testing/Servicing: Make/Model of Monitoring System: VR — 350 B. Inventory of Equipment Tested/Certified Check thea ro date bones[o indicates ecific a ui ment ins ected/serviced' Tank ID: ModeL- TanklD: 1 — Diesel South ❑ In-Tank Gauging Probe. Model: MA�� p Annular Space or Vault Sensor. Model:_ Q In-Tack Gauging Probe. P g p Model: Q Annular Space or Vault Sensor. Model: 30� ❑ Pi in Sum /Trench Sensor(s). ❑ Fill Sump Sensor(s). Model, Q Piping Sump/Trench Sensor(s). Model: 208 G Mechanical Line Leak Detector. Model---- Model: oder Model: 20� Model: Q Fill Sump Sensor(s). ❑ Electronic Line Leak Detector. Q Mechanical Line Leak Detector. Model: 99LD G Tank Overfill/High-Level Sensor. Model:------ u Electronic Line Leak Detector. Model:— ❑ Tank Overfill/High-Levet Sensor. Model: Othr'(specify equipment type and model in Section E on Page 2). Q Other(s ecify a ui ment a and model in Section E on Page 2). Tank D''_ Modeh--� Tank ID- 2 — Dlesel North Mor' — 7 :01 In-1 enk Gauging Probe. Model Q In-Tank Gauging Probe. Model'�� G Annular Space or Vault Sensor. Model:— � Sum Q Annular Space or Vault Sensor. Model: 30� ❑ Piping p/Trench Sensor(s). � Fill Sump Sensor(s). Model: Q Piping Sump/Trench Sensor(s). Model: X08 Mechanical Line Leak Detector. Model:_ Model: 208 Model: Q Fill Sump Sensor(s). mai n2DDD ❑ Electronic Line Leak Detector. � Q Mechanical Linnee Leak Detector. Model: 3 Tank Overfill/High-Level Sensor. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model:� L] other(specify equipment type and model in Section E on Page Q Other(specify equi ment t e and model in Section E on Pae 2). Dispenser ID: 16 Dispenser ID: 13 ❑ Dispenser Containment Sensor(s). Model: 208 Q Dispenser Containment Sensor(s). Model: 20� 13 Shear Valve(s). Q Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dis enser Containment Floats and Chains . Dispenser ID: 17 Dispenser 1D: 14 �� Q Dispenser Containment Sensor(s). Model: 208 Q Dispenser Containment Sensor(s). Model: 2 Q Shear Valve(s). Q ShearValve(s). ❑ Dis Baser Containment Floats and Chains . ❑ Dis enser Containment Float(s)and Chain s . L;spen:.-r:D: 18 Dispenser ID: 15 Q Dispenser Containment Sensor(s). Model: 208 Q Dispenser Containment Sensor(s). Model: 208 Q She.. Valve(s). Q Shear Valve(s). ❑ Dis enser Containment Floats and Chains . ❑ Dis enser Containment Float(s and Chain s . *If the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser ator identified in this the facility. document ed in accordance the C. Certificatio uidI ceAttchedo e rtif hequipme cation s information (e.g. manuf ctu ers' checklists) necessary to verifyvtha this manufacturers' information is correct and a Plot Plan showing the layout of monitoring e4O Scstem set-up equipment© generating such Alarm history report reports,I have also attached a copy of the report;(check all that apply) y Technician Name(print): AI Milburn Signature: (fZ Certification No: A27843 License.No. 956953 Testing Company Name: EPIC Compliance Systems Inc. Phone No. 888-700-EPIC Testing Company Address: 1435 HUntington Ave Suite 230 Date of Testin Servicing: 5/23/2011 South San Francisco CA 94080 Rev.06/04/01 Page 1 of 5 UN-036-1/4 "w.unidocs.org