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romallac 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 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 Manthey Rd. City: Stockton, CA Zip: 95206 Facility Contact Person: Nancy Le Contact Phone No.: (209) 462-7621 Make/Model of Monitoring System: VR -350 Date of Testing/Servicing: 03/11/08 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment insvected/serviced: Tank ID: 1-87 Tank ID: 3 -Diesel ® In -Tank Gauging Probe. Model: MAG -1 21 In -Tank Gauging Probe. Model:—MAG-1 21 Annular Space or Vault Sensor. Model: 794390-409 lK Annular Space or Vault Sensor. Model: 794390-409 El Piping Sump /Trench Sensor(s). -Model: 794380-208 © Piping Sump / Trench Sensor(s). Model: 794380-208 ❑ Fill Sump Sensor(s). Model: ❑ Fill SumpSensor(s). Model: ® Mechanical Line Leak Detector. Model: LD -2000 21 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 equipment ty and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: 2-91 Tank ID• ® In -Tank Gauging Probe. Model: MAG -1 ❑ In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 794390-409 ❑ Annular Space or Vault Sensor. Model: IE Piping Piping Sump /Trench Sensor(s). Model: 794380-208 Piping Sump / Trench Sensor(s). Ll Fill Sump Sensor(s). Model: Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ® 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 equipment type 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 FXI Dispenser Containment Sensor(s). Model: 794380-208 ® Dispenser Containment Sensor(s). Model: 794380-208 N] Shear Valve(s). O Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 3-4 Dispenser ID: N1 Dispenser Containment Sensor(s). Model: 794380-208 ❑ Dispenser Containment Sensor(s). Model: 0 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: ® Dispenser Containment Sensor(s). Model: 794380-208 ❑ Dispenser Containment Sensor(s). Model: ® 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): IR System set-up ® Alarm history report Technician Name (print): Alvin L. Milburn Signature: Certification No.: A27843 License. No.: 880430 Testing Company Name: EPIC Compliance Systems, Inc. Phone No.: 888 -777 -EPIC Site Address: 2224 Manthey Rd., Stockton Date of Testing/Servicing: 03/11/08 UN -036 -1/4 Page 1 of 4 Rev. 06/04/01 www.unidocs.org