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MONi..ORING SYSTEM CERTIIv AT E`�C 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 egt(�r�onsi a. Lj This form must be used to document testing and servicing of monitoring equipment. A separate certifi r e ort must be prepared for each monitoring system control panel by the technician who performs the work. A copy of this form vided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local aget"�a�ng UST systems within 30 days of test date. HSAtT�ri)NA,;ejVr, 7y A. General Information � PARTMeo Facility Name: Quickie Kleen Bldg.No.: --------- Site Address: 707 E Yosemite Ave City: Manteca Zip: 95336 Facility Contact Person: Francene Escobar Contact Phone No.: 209-814-6274 Make/Model of Monitoring System: V/R TLS 350 Date of Testing/Servicing: 10/21/2009 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: Regular 1 TanklD: M In-Tank Gauging Probe. Model: MAG-1 IM In-Tank Gauging Probe. Model: MAG-1 I]Annular Space or Vault Sensor. Model: 794380-420 0 Annular Space or Vault Sensor. Model: ©Piping Sump/Trench Sensor(s). Model: 794380-208 IM Piping Sump/Trench Sensor(s). Model: 794380-208 0 Fill Sump Sensor(s). Model: 0 Fill Sump Sensors). Model: 91 Mechanical Line Leak Detector. Model: STD-STP ❑x Mechanical Line Leak Detector. Model: STD-STP-D 0 Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: 0 Tank Overfill/High-Level Sensor. Model: 0 Tank Overfill/High-Level Sensor. Model: 0 Other(specifX equipment a and model in Section E on Pae 2). 0 Other(specify a ui ment lype and model in Section E on P2Se 2). Tank in: Regular 2 (Premium) Tank ID: IM In-Tank Gauging Probe. Model: MAG-1 0 In-Tank Gauging Probe. Model: 0 Annular Space or Vault Sensor. Model: 0 Annular Space or Vault Sensor. Model: IM Piping Sump/Trench Sensor(s). Model: 794380-208 0 Piping Sump/Trench Sensor(s). Model: 0 Fill Sump Sensor(s). Model: 0 Fill Sump Sensor(s). Model: OO Mechanical Line Leak Detector. Model: STD-STP 0 Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: 0 Tank Overfill/High-Level Sensor. Model: 0 Tank Overfill/High-Level Sensor. Model: 0 Other(specify equipment and model in Section E on Pa a 2). 0 Other(specify equipment t e and model in Section E on Page 2). Dispenser ID: 1/ 2 Dispenser ID: 7/ 8 ❑O Dispenser Containment Sensor(s). Model: 208 O Dispenser Containment Sensor(s). Model: 208 ❑O Shear Valve(s). O Shear Valve(s). 0 Dispenser Containment Floats and Chain (s). 0 Dispenser Containment Float(s)and Chains . Dispenser ID: 3/ 4 Dispenser ID: ❑O Dispenser Containment Sensor(s). Model: 208 0 Dispenser Containment Sensor(s). Model: 1XI Shear Valve(s). 0 Shear Valve(s). 0 Dispenser Containment Floats and Chain(s). 0 Dispenser Containment Floats and Chain s). Dispenser ID: 5/ 6 Dispenser ID: ®Dispenser Containment Sensor(s). Model: 208 0 Dispenser Containment Sensor(s). Model: ©Shear Valve(s). 0 Shear Valve(s). 0 Dispenser Containment Floats and Chains . 0 Dispenser Containment Floats 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): IM System set-up 0 Alarm history report Technician Name(print): Keith Huston Signature: Certification No.: A25577 License.No.: 880430 Testing Company Name: EPIC Compliance Systems, LLC Phone No.: 888-700-EPIC Testing Company Address: 1001 Bavhill Dr, Suite 150 Date of Testing/Servicing: 10/21/2009 UN-036-1/4 Page I of 4 Rev.06/04/01 www.unidoes.org