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MONITORING SYSTEM CERTIFICATION For Use By Al/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 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: 6/20/2012 B. Inventory of Equipment Tested/Certified Checkthe appropriate boxes to indicatespecific equipment inspected/serviced: TanklD: 1 - 87 Tank ID: 3 — Diesel Z In-Tank Gauging Probe. Model: MAG-7 Z In-Tank Gauging Probe. Model: MAG-7 Z Annular Space or Vault Sensor. Model: 303 Z Annular Space or Vault Sensor. Model: 303 Z Piping Sump/Trench Sensor(s). Model: 208 Z Piping Sump/Trench Sensor(s). Model: 208 Z Fill Sump Sensor(s). Model: 208 Z Fill Sump Sensor(s). Model: 208 Z Mechanical Line Leak Detector. Model: 99LD2000 Z 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: ❑ Other(specify equipment and model in Section E on Pae 2). ❑ Other(specify a ui ment type and model in Section E on Pae 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 ❑ Annular Space or Vault Sensor. Model: Z Piping Sump/Trench Sensor(s). Model: 208 ❑ Piping Sump/Trench Sensor(s). Model: Z Fill Sump Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: Z Mechanical Line Leak Detector. Model: 99LD2000 U Mechanical Line Leak Detector. Model: l7 Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: l7 Tank Overfill/High-Level Sensor. Model ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment a and model in Section E on Pae 2). O Other(specify equipment type and model in Section E on Page 2). Dispenser ID: 1 / 2 Dispenser D): 7 / 8 Z Dispenser Containment Sensor(s). Model: 208 Z Dispenser Containment Sensor(s). Model: 208 Z Shear Valve(s). Z Shear Valve(s). ❑ Dispenser Containment Floats and Chains). ❑ Dis nser Containment Floats and Chain (s). Dispenser ID: 3 / 4 Dispenser ID: 9 / 10 Z Dispenser Containment Seasons). Model: 208 Z Dispenser Containment Sensor(s). Model: 208 Z Shear Valve(s). Z Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dis nser Containment Float(s)and Chain(s). Dispenser ID: S / 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). ❑ Dispenser Containment Floats 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): 0 System set/-up 0 Alarm history report Technician Name(print): Al Milburn Signature: 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: 6/20/2012 UN-036-1/4 Page I of 5 Rev.06/04/01 wsvw.unidoes.org