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MONARING SYSTEM CERTI4ATION 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 wor�° f t be provided to the tank system owner/operator. The owner/operator must submit a copy of this form tM 1 t g UST systems within 30 days of test date. A. General Information DEC 20 2010 Facility Name: Fast Lane-Lathrop (Auto) Bid No.: EX111Rnhuaca TAl_HEM Site Address: 116 East Roth Road City: Lath rOORMIT/SERVICES Zip: 95330 Facility Contact Person: Hardeep Gill Contact Phone No.: 707-326-0369 Make/Model of Monitoring System: VR-350 Date of Testing/Servicing: 11/22/2010 B. Inventory of Equipment Tested/Certified Check the aegropriate boxes to indicatespecific equipment ins ected/serviced: Tank ID: 1 — 87 Tank ID: 3 — Diesel 0 In-Tank Gauging Probe. Model: MAG-7 0 In-Tank Gauging Probe. Model: MAG-7 0 Annular Space or Vault Sensor. Model: 303 0 Annular Space or Vault Sensor. Model: 303 0 Piping Sump/Trench Sensor(s). Model: 208 0 Piping Sump/Trench Season(s). Model: 208 0 Fill Sump Sensor(s). Model: 208 0 Fill Sump Sensor(s). Model: 208 0 Mechanical Line Leak Detector. Model: 99LD2000 0 Mechanical Line Leak Detector. Model: STP-MLD-D ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: 0 Other(specify equipment a and model in Section E on Pa e 2). 7 Other�s2ecifX equipment a and model in Section Tank ID: 2 — 91 Tank ID: 7 In-Tank Gauging Probe. Model: MAG-7 ❑ In-Tank Gauging Probe. Model: 0 Annular Space or Vault Sensor. Model: 303 ❑ Annular Space or Vault Sensor. Model: 0 Piping Sump/Trench Sensor(s). Model: 208 ❑ Piping Sump/Trench Sensor(s). Model: 0 Fill Sump Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: 99LD2000 O Mechanical Line Leak Detector. Model: ❑ El Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Leve]Sensor. Model: C3 Tank Overfill/High-Level Sensor. Model: 0 Other(s eci a ui ment type and model in Section E on Page 2). ZI Other(specify equipment type and model in Section E on Page 2). Dispenser ID: 1 / 2 Dispenser ID: 7 / 8 0 Dispenser Containment Sensor(s). Model: 208 0 Dispenser Containment Sensor(s). Model: 208 7 Shear Valve(s). 0 Shear Valve(s). C3 Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: 3 / 4 Dispenser ID: 9 / 10 0 Dispenser Containment Sensor(s). Model: 208 0 Dispenser Containment Sensor(s). Model: 208 D Shear Valve(s). 0 Shear Valve(s). ❑ Dispenser Containment Floats and Chain (s). ❑ Dispenser Containment Floats and Chains . Dispenser ID: 5 / 6 Dispenser ID: 11 / 12 0 Dispenser Containment Sensor(s). Model: 208 0 Dispenser Containment Sensor(s). Model: 208 0 Shear Valve(s). 0 Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dispenser 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): ❑x System set-up O Alarm history report Technician Name(print): Al Milburn Signature: Certification No.: A27843 License.No.: 90-1409 (CA tank test license) Testing Company Name: EPIC Compliance Systems, LLC PhoneNo.: 888-700-EPIC Testing Company Address: 1435 Huntington Ave, Suite 230 South San Francisco, CA 94080 Date of Testing/Servicing: 11/22/2010 UN-036-1/4 Page 1 of 5 Rev.06/04/01 w .unidocs.org