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MONITORING SYSTEM CERTIFICATION rm/ vc 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 p orms the work. A copy of this form must be provided to the tank system owner/operator. The owner/operPP411;c)� }� agency regulating y this form to the local a enc re ulatin UST systems within 30 days of test date. A. General Information D E-"I 3 1 �1 Facility Name: Gas Depot pr �Ax�r-.. - s �. Bldg.No.: :ems ,�„�.Trl._�� „�_rsc.r.a Site Address: 1330 E. Yosemite Ave PFPFtAIT/ chi/6r-!=c, City: Manteca, CA Zip: 95336 Facility Contact Person: Ricky Contact Phone No.: 209-825-0332 Make/Model of Monitoring System: VR-350 Date of Testing/Servicing: 11/25/08 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: 1 - 87 Tank ID: 3 - Diesel ®In-Tank Gauging Probe. Model: MAG-1 ❑x In-Tank Gauging Probe. Model: MAG-1 ❑O Annular Space or Vault Sensor. Model: 409 ❑x Annular Space or Vault Sensor. Model: 409 O Piping Sump/Trench Sensor(s). Model: 352 ❑x Piping Sump/Trench Sensor(s). Model: 352 ❑O Fill Sump Sensor(s). Model: 208 O Fill Sump Sensor(s). Model: 208 ❑x Mechanical Line Leak Detector. Model: 99 LD 2000 ❑O Mechanical Line Leak Detector. Model: 99 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 aqui mint ty e and model in Section E on Pae 2). ❑ Other(specify equipment a and model in Section E on Pae 2). Tank ID: 2 - 91 Tank ID: 21 In-Tank Gauging Probe. Model: MAG-1 ❑ In-Tank Gauging Probe. Model: ®Annular Space or Vault Sensor. Model: 409 ❑ Annular Space or Vault Sensor. Model: ❑x Piping Sump/Trench Sensor(s). Model: 352 ❑ Piping Sump/Trench Sensor(s). Model: 0 Fill Sump Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: O Mechanical Line Leak Detector. Model: 99 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 a and model in Section E on Pae 2). ❑ Other(specify equipment type and model in Section E on Page 2). Dispenser ID: 1/2 Dispenser ID: 7/8 ❑x Dispenser Containment Sensor(s). Model: 322 O Dispenser Containment Sensor(s). Model: 322 M Shear Valve(s). ❑x Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: 3/4 Dispenser ID: 9/10 ❑x Dispenser Containment Sensor(s). Model: 322 Mx Dispenser Containment Sensor(s). Model: 322 Mx Shear Valve(s). El Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: 5/6 Dispenser[D: 11/12 ❑O Dispenser Containment Sensor(s). Model: 322 O Dispenser Containment Sensor(s). Model: 322 ❑x Shear Valve(s). El Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). I ❑ 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/seryiced 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): ❑x System set-up El Alarm history report Technician Name(print): Alvin L. Milburn Signature: Certification No.: A32784 License.No.: 880430 Testing Company Name: EPIC Compliance Systems, Inc. Phone No.: 888-777-EPIC Testing Company Address: 2400 San Bruno Ave, San Francisco, CA Date of Testing/Servicing: 11/25/08 UN-036-1/4 Page 1 of 4 Rev.06/04/01 www.unidoes.org