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MONITORING SYSTEM CERTIFICATION-REVISED P 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: Ouicki Kleen Bldg.No.: Site Address: 707 E. Yosemite Ave City: Manteca CA Zip: 95336 Facility Contact Person: Francene Contact Phone No.: (209) 814-6274 Make/Model of Monitoring System: VR-350 Date of Testing/Servicing: 11/21/08 B. Inventory of Equipment Tested/Certified Check the appropriatt boxes to indicatespecific equipment inspected/serviced: Tank ID: 1-87 South TanklD: 3-Diesel ®In-Tank Gauging Probe. Model: MAG-0 ®In-Tank Gauging Probe. Model: MAG-0 ®Annular Space or Vault Sensor. Model: 450 171 Annular Space or Vault Sensor. Model: Same 0 Piping Sump/Trench Sensor(s). Model: 208 ®Piping Sump/Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ®Mechanical Line Leak Detector. Model: STP-MLD ©Mechanical Line Leak Detector. Model: STP-MLD ❑ 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 equipment and model in Section E on Page 2 . Tank ID: 2-87 Middle Tank ID: 21 In-Tank Gauging Probe. Model: MAG-0 ❑ In-Tank Gauging Probe. Model: El Annular Space or Vault Sensor. Model: Same ❑ Annular Space or Vault Sensor Model: 0 Piping Sump/Trench Sensor(s). Model: 208 ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: E Mechanical Line Leak Detector. Model: STP-MLD ❑ 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 Senscr. Model: ❑ Other(specify equipment and model in Section E on Page 2). ❑ Other(specify equipment and model in Section E on Page 2). DispenserlD: 1-2 DispenserlD: 7-7 O Dispenser Containinent Sensor(s). Model: 208 O Dispenser Containment Sensm(s). Model: 208 El Shear Valve(s). ®Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dis enser Containment Floats and Chains. Dispenser ID: 3-4 Dispenser ID: IM Dispenser Containment Sensor(s). Model: 208 ❑ Dispenser Containment Senwr(s). Model: 0 Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chains . I ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: 5-6 Dispenser ID: El Dispenser Containment Sensm(s). Model: 208 ❑ Dispenser Containment Sensor(s). Model: ®Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Floats and Chain(s). elf 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,1 have also attached a copy of the report;(check all that apply): 0 System set-up O Alarm history report Technician Name(print): Alvin L. Milburn Signature: Certification No.: A27843 License.No.:880430 Testing Company Name: EPIC Compliance Systems Inc PhoneNo.: 888-777-EPIC Testing Company Address: 2400 San Bruno Ave. San Francisco. CA Date of Testing/Servicing: 11/21/08 UN-036-1/4 Page I of 4 Rev.06/04/01 www.unidocs.org