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• • MONITORING SYSTEM CERTIFICATIONrmll �� For Use By All Jurisdictions Within the State of California a.,�, 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: Kwik Serve Bldg. No.: Site Address: 950 W. 11th Street City: Tracy, CA Zip: 95376 Facility Contact Person: Patel Contact Phone No.: (209) 832-1810 Make/Model of Monitoring System: VR TLS 350 Date of Testing/Servicing: 10/30/08 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: T-1 Diesel Tank ID: T-3 87 O In -Tank Gauging Probe. Model: MAG -1 0 In -Tank Gauging Probe. Model: MAG -1 ❑x Annular Space or Vault Sensor. Model: 794390-407 D Annular Space or Vault Sensor. Model: 794390-407 O Piping Sump / Trench Sensor(s). Model: 794390-208 ❑x Piping Sump / Trench Sensor(s). Model: 794390-208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑x Electronic Line Leak Detector. Model: VR PLLD I] Electronic Line Leak Detector. Model: VR PLLD ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other s eci equipment and model in Section E on Pae 2). ❑ Other(specify equipment t and model in Section E on P e 2). Tank ID: T-2 91 Tank ID: ❑x In -Tank Gauging Probe. Model: MAG -1 ❑ In -Tank Gauging Probe. Model: ❑x Annular Space or Vault Sensor. Model: 794390-407 ❑ Annular Space or Vault Sensor. Model: ❑x Piping Sump / Trench Sensor(s). Model: 794390-208 ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: O Electronic Line Leak Detector. Model: VR PLLD ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other(specify equipment a and model in Section E on P e 2 . ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: 1-2 Dispenser ID: 7-8 ❑O Dispenser Containment Sensor(s). Model: 208 El Dispenser Containment Sensor(s). Model: 208 O Shear Valve(s). El Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dis nser Containment Floats and Chain(s). Dispenser ID: 3-4 Dispenser ID: ❑X Dispenser Containment Sensor(s). Model: 208 ❑ Dispenser Containment Sensor(s). Model: ❑X Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). I ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5-6 Dispenser ID: O Dispenser Containment Sensor(s). Model: 208 ❑ Dispenser Containment Sensor(s). Model: Fxl Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) 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): ❑ System set-up ❑ Alarm history report Technician Name (print): Alvin L. Milburn Signature: Certification No.: A27843 Testing Company Name: EPIC Compliance Systems, Inc. Testing Company Address: 2400 San Bruno Ave, San Francisco, CA UN -036 - 1/4 Page I of 4 www.unidoes.org License. No.: 880430 Phone No.: 888 -777 -EPIC Date of Testing/Servicing: 10/30/08 Rev. 06/04/01