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MONIARING SYSTEM CERTIFMATION For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7,Health and Safety Code; Chapte-16, Vii,,,^inn 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitor:-; 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 FacilityName: Fast Lane-Lathrop (Auto) Bldg.No. — Site Address: 116 E Roth Road 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: 5/23/2011 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment ins ected/mrviced: Tank 1D:_1 — 87 Tank M: 3 — Diesel Z In-Tank Gauging Probe. Model: MAG-7 01n-Tank Gauging Probe. Model: MAG-7 Z Annular Space or Vault Sensor. Model: 303 0 Annular Space or Vault Sensor. Model: 303 0 Piping Sump/Trench Sensor(s). Model: 208 Ed Piping Sum,:/Trench Sensor(s). Model: 208 Z Fill Sump Sensor(s). Model: 208 0 Fill�: :p Sensor(s). Model: 208 Z Mechanical Line Leak Detector. Model: 99LD2000 Z Meenanical Line Leak Detector. Model: STP-MLD-D ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: 3 Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: Z Other(specify equipment type and model in Section E on Page 2). j ❑ Other(specify equipment type and model in Section E on Page 2). Tank ID: 2 - 91 Tank ID: Z In-Tank Gauging Probe. Model: MAG-7 ❑ In-Tank Gauging Probe. Model: Z Annular Space or Vault Sensor. Model: 303 3 Annular Space or Vault Sensor. Model: Z Piping Sump/Trench Sensor(s). Model: 208 ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Z Fill Sump Sensor(s). Model: 208 ❑ Mechanical Line Leak Detector. Model: Z Mechanical Line Leak Detector. Model: 99LD2000 13 Electronic Line Leak Detector. Model: i3 Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: 13 Tank Overfill/High-Level Sensor. Model: 13 Other(specify equipment type and model in Section E on Page 2). Z Other(specify equipment t e and model in Section E on Page 2). Dispenser ID: 1 / 2 Dispenser ID: 7 / 8 Z Dispenser Containment Sensor(s). Model: 208 Z Dispenser Containment Sensor(s). Model: 208 Z Shear Valve(s). Z Shear Valve(s). D Dispenser Containment Float(s)and Chain(s). r't Dis -user Containment Floats and Chains . Dispenser ID: 3 / 4 Disperser ID: 9 / 10 Z Dispenser Containment Sensor(s). Model: 208 Z Dis; user Containment Sensor(s). Model: 208 Z Shear Valve(s). Z Shear Valve(s). ❑ Dispenser Containment Floa s and Chain(s). ❑ Dis enser Containment Floats and Chain (s). Dispenser ID: 5 / 6 Dispenser ID: 11 / 12 Z Dispenser Containment Sensor(s-). Model: 208 Z Dispenser Containment Sensor(s). Model: 208 Z Shear Valve(s). Z Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). 3 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 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): © System sett-up ❑X Alarm history report Technician Name(print): AI Milburn Signature: �Z_1z2 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 South San Francisco, CA 94080 Date of Testing/Servicing: 5/23/2011 UN-036-1/4 Pagel of 5 Rev.06/04/01 www.unidocs.org