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ONI RING SYSTEM CETIF NATION For U.se 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 thework. A co of this form must be provided to the tank system owner/operator. The owner/operator must submit a copy o 1 cy regulating UST systems within 30 days of test date. A. General Information j Facility Name: California Stop Bldg.No: — Site Address: 2224 Manthey Road Zip: 95026 Facility Contact Person: Timmy Le Contact Phone No.: 209-462-7621 Make/Model of Monitoring System: V/R TLS 350 Date of Testing/Servicing: 3/15/2011 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment ins ected/serviced: Tank ID: 87 Tank ID: Diesel Q In-Tank Gauging Probe. Model: MAG-1 Q In-Tank Gauging Probe. Model: MAG-1 Q Annular Space or Vault Sensor. Model: 794390-407 Q Annular Space or Vault Sensor. Model: 794390-407 Q Piping Sump/Trench Sensor(s). Model: 794380-208 Q Piping Sump/Trench Sensor(s). Model: 794380-208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Q Mechanical Line Leak Detector. Model: 99LD2000 Q Mechanical Line Leak Detector. Model: 99LD2000 ❑ 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 t e and model in Section E on Page 2). ❑ Other(specify equipment t e and model in Section E on Pa e 2). Tank ID: 91 Tank ID: -- Q In-Tank Gauging Probe. Model: MAG-1 ❑ In-Tank Gauging Probe. Model: Q Annular Space or Vault Sensor. Model: 794390-407 ❑ Annular Space or Vault Sensor. Model: Q Piping Sump/Trench Sensor(s). Model: 794380-208 ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Q Mechanical Line Leak Detector. Model: 99LD2000 ❑ 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: ❑ 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). Dispenser ID: 1 / 2 Dispenser ID: 7 / 8 Q Dispenser Containment Sensor(s). Model: 208 QDispenser Containment Sensor(s). Model: 208 Q Shear Valve(s). QShear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 3 / 4 Dispenser ID: Q Dispenser Containment Sensor(s). Model: 208 ❑ Dispenser Containment Sensor(s). Model: Q Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5 / 6 Dispenser ID: Q Dispenser Containment Sensor(s). Model: 208 ❑ Dispenser Containment Sensor(s). Model: Q Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chains . ❑ 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 0 Alarm history report -- Technician Name(print): Keith Huston Signature: ;e4�� Certification No.: A25577 License.No. 956953 Testing Company Name: EPIC Compliance Systems, Inc Phone No.: 888-700-EPIC Testing Company Address: 1435 Huntington Ave, Suite 230 South San Francisco, CA 94080 Date of Testing/Servicing: 3/15/2011 UN-036-1/4 Page 1 of 4 Rev.06/04/01 www.unidoes.org