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MONIOAPJNG SYSTEM CETI ATI �arr.`Ms 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: Tracy Truck Stop Bldg.No.: Site Address: 3940 N Tracy Blvd City: Tracy Zip: 95304 Facility Contact Person: Debbie 7utla Contact Phone No.: 209-832-5006 Make/Model of Monitoring System: Veeder-Root TLS 350 Date of Testing/Servicing: 04/02/2010 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: TankID: TankID: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ 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 a and model in Section E on Pae 2). ❑ Other(specify equipment t e and model in Section E on Pae 2). Tank ID: Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ 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(s eci equi ment a and model in Section E on Pae 2). ❑ Other(specify equipment type and model in Section E on Pae 2). Dispenser ID: 12 — 13A Dispenser ID: 13 — 14A ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). 0 Shear Valve(s). • Dispenser Containment Float(s)and Chain(s). 0 Dispenser Containment Float(s)and Chain(s). Dispenser ID: 14 — 15A Dispenser ID: 15 — 16A ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: * Shear Valve(s). Z Shear Valve(s). Ox Dispenser Containment Float(s)and Chain(s). Z Dispenser Containment Float(s)and Chain s). Dispenser ID: 16 — 17A Dispenser ID: 17 - 18 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: I@ Shear Valve(s). 0 Shear Valve(s). 9 Dispenser Containment Float(s)and Chain(s). Ox 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): [K] System set-up I]Alarm history report Technician Name(print): Keith Huston Signature: Certification No.: A25577 License.No.: 880430 Testing Company Name: EPIC Compliance Systems, LLC Phone No.: 888-700-EPIC Testing Company Address: 1001 Bayhill Dr, Suite 150 Date of Testing/Servicing: 04/02/2010 UN-036-1/4 Page 1 of 4 Rev.06/04/01 www.unidocs.org