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MONI A RING SYSTEM CERTIF ATION MW E For Use By All Jurisdictions Within the State of California 005 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: California Stop Bldg. No.: Site Address: 2224 S Manthey City: Stockton Zip: 95206 Facility Contact Person: Nancy Lee Contact Phone No.: 209-462-7621 Make/Model of Monitoring System: Veeder-Root TLS 350 Date of Testing/Servicing: 03/17/2010 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: Regular Tank ID: Diesel 0 In -Tank Gauging Probe. Model: MAG -1 ❑x In -Tank Gauging Probe. Model: MAG -1 • Annular Space or Vault Sensor. Model: 794390-407 N Annular Space or Vault Sensor. Model: 794390-407 • Piping Sump / Trench Sensor(s). Model: 794380-208 9 Piping Sump / Trench Sensor(s). Model: 794380-208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: M Mechanical Line Leak Detector. Model: LD 2000 0 Mechanical Line Leak Detector. Model: LD 2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify e ui ment t e and model in Section Eon Pa e 2 . ❑ Other (specify equipment t e and model in Section E on Pa Le 2). Tank ID: Premium Tank ID: • In -Tank Gauging Probe. Model: MAG -1 ❑ In -Tank Gauging Probe. Model: • Annular Space or Vault Sensor. Model: 794390-407 ❑ Annular Space or Vault Sensor. Model: © Piping Sump / Trench Sensor(s). Model: 794380-208 ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: O Mechanical Line Leak Detector. Model: LD 2000 ❑ 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 type and model in Section E on Pae 2). ❑ Other (speciLy equipment ty e and model in Section E on Pae 2). Dispenser ID: 1/2 Dispenser ID: 7/8 0 Dispenser Containment Sensor(s). Model: 794980-208 ❑x Dispenser Containment Sensor(s). Model: 794980-208 0 Shear Valve(s). N Shear Valve(s). Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: 3/4 Dispenser ID: © Dispenser Containment Sensor(s). Model: 794980-208 ❑ Dispenser Containment Sensor(s). Model: O Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). I ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: 5/6 Dispenser ID: ❑x Dispenser Containment Sensor(s). Model: 794980-208 ❑ Dispenser Containment Sensor(s). Model: 9 Shear Valve(s). ❑ Shear Valve(s). ❑ Dis enser Containment Float(s) and Chain(s). ❑ 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): ® System set-up IR Alarm history report Technician Name (print): Keith Huston Certification No.: A25577 Testing Company Name: EPIC Compliance Systems, LLC Testing Company Address: 1001 Bayhill Dr, Suite 150 UN -036 1/4 Page I of 4 www.unidoes.org Signature: License. No.: 880430 Phone No.: 888 -700 -EPIC Date of Testing/Servicing: 03/17/2010 Rev. 06/04/01