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MONI'r()RING SYSTEM CERTIFteATION 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 perforans 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: Quicki Kleen Bldg.No.: Site Address: 707 E Yosemite Ave City: Manteca,CA Zip: 95336 Facility Contact Person: Francene Escobar Contact Phone No.: 209-814-3726 Make/Model of Monitoring System: VR-350 Date of Testing/Servicing: 10-18-2010 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: 87 South Tank ID: 3 - Diesel 0 In-Tank Gauging Probe. Model: MAG-0 0 In-Tank Gauging Probe. Model: MAG-0 0 Annular Space or Vault Sensor. Model: 420 0 Annular Space or Vault Sensor. Model: 420 0 Piping Sump/Trench Sensor(s). Model: 208 0 Piping Sump/Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: STP-MLD 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: i I Tank Overfill/High-Level Sensor. Model: ❑ other(specify equipment t e and model in Section E on Page 2). ❑ Other�Tecify equipment t e and model in Section E on Page 2). Tank m: 87 Middle Tank ID: 0 In-Tank Gauging Probe. Model: MAG-0 ❑ In-Tank Gauging Probe. Model: 0 Annular Space or Vault Sensor. Model: 420 ❑ 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: 0 Mechanical Line Leak Detector. Model: STP-MLD i7 Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: i7 Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: i7 Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Pa e 2). O 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 0 Shear Valve(s). 0 Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). i I Dispenser Containment Floats and Chain(s). Dispenser ID: 3/4 Dispenser ID: 0 Dispenser Containment Sensor(s). Model: 208 ❑ Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). ❑ Shear Valve(s). ❑ Dis enser Containment Floats and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5/6 Dispenser ID: 0 Dispenser Containment Sensor(s). Model: 208 ❑ Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). ❑ 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): ❑O 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: 10-18-2010 UN-036-1/4 Page I of Rev.06/04/01 www.unidocs.org