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APR-30-2010 FRI 05: 42 PM P. 040 04/28/2010 13:26 6613930 CHUCX HILL PAGE 01/07 MONITORING SYSTEM CERTUTCATION For Use UYAll Jwwaloonr Within rhe&arc of Cal ybrwa ,4 Whoriot Ckeek-Chapter 6.7, Ifeakh and Safe*,Code, Chapter 16, D&ISion 3, Mle 23,Cal#bmda C6d,,,qfRegujwj0AT This (brim must be used to doc mcrit testing and $erviCing of monitoring eqaiprnent. A wvanft C(23tftatiorl or rraact be pre each mon MD—Mftl by the tmimicim who pw&rrns the work. A copy of this form must be provided to the tank system ovmr/operaWr. The mmer/operator nwst submit a WPY Of this form W the local agency reptafmg UST system Wfthift 30 days oftw d=4 A. General Informafien Fadlityl%famec:_ , i- Site Address: 3_940 N,Trl!Ze Blvd City:--jmaz Zip., --9_5304 Facilitvt=Pm.on: Con 01btle jutla contwt Phone No.: . 209-8-327 MakeModel of Monitoring Symm:---Y99de--r--RP-qt TLS 350 Date of Testing(Servicing: -- lo B. Inventory of Equipment Teste&Cerfified Check the a le be=m Lueetam—cm ti Tank JD-._�-" - az TAnk M.—Z -91 0 In-Tank Gauging Probe. MA-G ~^ 0 in-Tank Gauging Probe, Modcl. 0 AnnuW Spa=or Vault Sensor. moclel. 420 CJ Annular Space or Vault Sensor. Model. S121;t with I 9 Piping Sump/T=ch Sensor(s� Model: --208- ® Ding Sump I Trench Sansor(s). Model; a 0 Fill Surnp Sensor(s). Model: Q MIT 5=P scrtsws). Model: 91 Mechanical Um Leak Detector. Model- -99La-2051Q_ DE MWmical Line Leak Detector- Modd., 9-9-—LD2DAQ_ U Electroniq Line Lc&Woctor- Modci; U Mectronic Linc Leak Damor, Model: P Tank Overfill I MO-Loyd S=wr, Model: E3 'rank Overfill I High-Level Sensor. Model: 13 Otba Lse2�fy Ep .]Mjad Wm and model in Section E an Pw 2). -- U 0dterL.%jMry ncnt on EjgL2 2T&r AIM in Spoon r =and Mr Tank ION 3 - Diesel I High also Tack 1M. 4 - Diesel 59 In-Tank Gauging Probe. Model: MAC 0 la-Tank Gimeng Probe- me"-- MAG 0 Annular Space or Vault Scnmr. Mom. ag 2;AMUIV Spam of Vault Sensor. Modd- 420 * Piping Sump'Tremb Scnsods)- Mo#ol-.. 0 Piping Sump ITrmwl Sensor(s). Model: 208 * Fill Sump Z�M%). mom: I Q F=all"Sensor(s). Mod& 91 Mechanical Lint Leak Detector, Model:LD3000/99LD2000 fig Mechanical line Leak Model: ID.,3_000 Q Electronic Lint Lcak Detector. Model.- 0 Electronic Line Leak Dctcctor. Model; Z Tank Overfill,'High-Level Senw. Model: Cl Tank Overlill I High-Level SaLw. Model, T3 Otber(sy cquivrnent tNve and model in Section E on r1w 4 E3 Other Lsett&-S2jp=t=and rnodai in Section E on ENE 2)- Disperwr W: - - I - ?. — Mpomper 11W, _ _ a -4 C3 Dispenser ConWnxnentqensot(s). Model: 13 Dispcnscr Containment Scnsor(-.;� Mo&L-. Is shear VW16*4 a Sbcar Valve(s). 0 DispCoser Cmabuncnt Fl=Liland 19 ser Corrtzinhent FT)and Cheri 2LsL. obvebw 11):.. L»6 - vis pomm FD: z- 91 13 D*xmscr Containment Sensor(s). Model: D Model. 9 Shcarvalvo(e). 0 Shear Vnlv--($). 91 Er=Cont;ajnmart njjQs and Chef sj Z Mqw=qqgLd(�cntand J EloalClmia(s). _ - mpeasser TD- —]UA Wopensor fl): U-- ---Cl Dispenser Contahmma Scn=r(s). Model- 0 Dispenser Containment Sensor(s). Model: 13 Shear Marvels)- a shear Valve(s). 13 Dimcpsor Con!!!v%mmt V-T2Ws and Chaln(0. le R.LSL=Containment Fl1 Ono chering- ,,if the 1Wthy owrteins more tanks or dispem.we,coag tris form. Include infonnation for every unk and dispenur at ft facility. C. Certification - v ccvt;f-.w that the equip maut ideeadflad in this document was tuspecteelAserviced N accordance with Me man: ens'Suideliam Attached to this Cerfirscmdon is information (eg,.axanufacturcrV checklists)necessary to v"that this information Is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of Zpnerxting such reports.I have also attached a cuff of the report~(check aN that app&: 0 System set-up CM Alarm hbftry report Tecbniciart Name(print): Kgjjh HUggn Sisnatufw- C4rdficabon No.: &;?55_77 LiconM No.:680430 Testing Company Name: ,EFMC ccsMilan= xw, VM,%-LLC Phom No:: 888-700-EPIC TostinS Company Aft"s. , 1801 ffWhill Dr. Suite 150 Date of Testing/Servicing: _0410_2/2010- U14-f"-tis Pup 1 of 4 Rev.06AMM