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MON9.bRING SYSTEM CERTIOATION 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 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(Truck Side) Bldg.No.: ----- Site Address: 116 East Roth Road City: Lathrop Zip: 95330 Facility Contact Person: Hardeep Gill Contact Phone No.: 707-326-0369 Make/Model of Monitoring System: VR TLS-350 Date of Testing/Servicing: October 27,2010 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates ecific equipment inspected/serviced: TanklD: 1- Diesel South Tank ID: I] In-Tank Gauging Probe. Model: Mag-7 ❑ In-Tank Gauging Probe. Model: O Annular Space or Vault Sensor. Model: 303 ❑ Annular Space or Vault Sensor. Model: O Piping Sump/Trench Sensor(s). Model: 208 ❑ Piping Sump/Trench Sensor(s). Model: 19 Fill Sump Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: Z Mechanical Line Leak Detector. Model: 99LD2000 O Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: O Other(specify equipment t e and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). Tank ID: 2-Diesel North Tank ID: O In-Tank Gauging Probe. Model: Mag-7 ❑ In-Tank Gauging Probe. Model: O 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: O Fill Sump Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: O Mechanical Line Leak Detector. Model: 99LD2000 I] Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: O Other(specify equipment a and model in Section E on Page 2). O Other(specify equipment type and model in Section E on Page 2). Dispenser ID: 13 Dispenser ID: 16 O Dispenser Containment Sensor(s). Model: 208 ❑O Dispenser Containment Sensor(s). Model: 208 O Shear Valve(s). ❑O Shear Valve(s). ❑ Dispenser Containment Floats and Chain (s). ❑ Dispenser Containment Floats and Chains . Dispenser ID: 14 Dispenser ID: 17 ❑O Dispenser Containment Sensor(s). Model: 208 D Dispenser Containment Sensor(s). Model: 208 ❑x Shear Valve(s). ❑x Shear Valve(s). ❑ Dispenser Containment Float(s) and Chains . ❑ Dis enser Containment Floats and Chain(s). Dispenser ID: 15 Dispenser ID: 18 ❑X Dispenser Containment Sensor(s). Model: 208 MI Dispenser Containment Sensor(s). Model: 208 M Shear Valve(s). lM Shear Valve(s). ❑ Dispenser Containment Floats 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): ❑X System set-up ❑O Alarm history report Technician Name(print): Al Milburn Signature: az 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: October 27,2010 UN-036-114 Page 1 of 4 Rev.06/04/01 wo,w.unidocs.org