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MONITORING SYSTEM CERTIFICATION -A For Use By All Jurisdictions Within the State of California wb_ 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 Road City: Stockton Zip: 95206 Facility Contact Person: Nancy Le Contact Phone No.: (209) 462-7621 Make/Model of Monitoring System: B. Inventory of Equipment Tested/Certified Check the annronriate boxes to indicates ecifir a ninment insnected/serviced: Date of Testing/Servicing: 03/27/2009 Tank ID: Regular Tank ID: Premium ® In -Tank Gauging Probe. Model: MAG -1 [M In -Tank Gauging Probe. Model: MAG -1 ® Annular Space or Vault Sensor. Model: 407 © Annular Space or Vault Sensor. Model: 407 ❑x Piping Sump / Trench Sensor(s). Model: 208 ❑x Piping Sump / Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: © Mechanical Line Leak Detector. Model: VMI LD2000 © Mechanical Line Leak Detector. Model: VMI LD2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other(specify a ui ment t e and model in Section E on Pa e 2 . ❑ Other (sgecify a ui ment type and model in Section E on Pa e 2). Tank ID: Diesel Tank ID: IM In -Tank Gauging Probe. Model: MAG -1 ❑ In -Tank Gauging Probe. Model: © Annular Space or Vault Sensor. Model: 407 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump / Trench Sensor(s). Model: 208 ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑O Mechanical Line Leak Detector. Model: VMI LD2000 ❑ 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 Pa e 2 . ❑ Other (s2ecify equipment t e and model in Section E on Page 2). Dispenser ID: 1-2 Dispenser ID: 3-4 El Dispenser Containment Sensor(s). Model: 208 ❑x Dispenser Containment Sensor(s). Model: 208 IM Shear Valve(s). ❑x Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑Dis enser Containment Floats and Chain(s). Dispenser ID: 5-6 Dispenser ID: 7-8 ® Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model: 208 O Shear Valve(s). © Shear Valve(s). ❑ Dispenser Containment Floats and Chains . ❑ Dispense Containment Floats and Chains . Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dis enser Containment Float(s) and Chain(s). ❑ Dis enser 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 Technician Name (print): Keith Huston Signature: Certification No.: A25577 License. No.: 880430 Testing Company Name: EPIC Compliance Systems, Inc. Phone No.: 888 -700 -EPIC Testing Company Address: 2400 San Bruno Ave. San Francisco, CA Date of Testing/Servicing: 03/27/2009 UN -036 -1/4 Page 1 of 4 Rev. 06/04/01 www.unidoes.org