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MONI RING SYSTEM CERTIF ATION 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 Blvd Shell Bldg.No. --- Site Address: 3725 Tracy Blvd City: Tracy, CA Zip: 95304 Facility Contact Person: Mojgan Anvari Contact Phone No.: 510-224-6922 Make/Model of Monitoring System: TLS-350 Date of Testing/Servicing: 1/5/2011 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: 1 - 87 Tank ID: 3 - 91 0 In-Tank Gauging Probe. Model: MAG-1 0 In-Tank Gauging Probe. Model: MAG-1 0 Annular Space or Vault Sensor. Model: 301 0 Annular Space or Vault Sensor. Model: 301 0 Piping Sump/Trench Sensor(s). Model: 208 0 Piping Sump/Trench Sensor(s). Model: 208 0 Fill Sump Sensor(s). Model: 208 0 Fill Sump Sensor(s). Model: 208 ❑ 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 ui ment type and model in Section E on Page 2). 1 ❑ Other s eci ui ment a and model in Section E on Page 2 . Tank ID: 2 - 89 Tank ID: 3 - Diesel 0 In-Tank Gauging Probe. Model: MAG-1 0 In-Tank Gauging Probe. Model: MAG-1 0 Annular Space or Vault Sensor. Model: 301 0 Annular Space or Vault Sensor. Model: 208 0 Piping Sump/Trench Sensor(s). Model: 208 0 Piping Sump/Trench Sensor(s). Model: 208 0 Fill Sump Sensor(s). Model: 208 ❑ 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(Tecify equipment t e and model in Section E on Pa e 2 . ❑ Other(specify equipment type and model in Section E on Page 2). Dispenser ID: 1 / 2 Dispenser ID: 7 / 8 0 Dispenser Containment Sensor(s). Model: Beaudreau 522 0 Dispenser Containment Sensor(s). Model: Beaudreau 522 0 Shear Valve(s). 0 Shear Valve(s). ❑ Dispenser Containment Floats and Chain (s). ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: 3 /4 Dispenser ID: 9 / 10 , 11 / 12 0 Dispenser Containment Sensor(s). Model: Beaudreau 522 0 Dispenser Containment Sensor(s). Model: Beaudreau 522 0 Shear Valve(s). 0 Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain (s). Dispenser ID: 5/ 6 Dispenser ID: 13 / 14 15 / 16 0 Dispenser Containment Sensor(s). Model: Beaudreau 522 0 Dispenser Containment Sensor(s). Model: Beaudreau 522 0 Shear Valve(s). 0 Shear Valve(s). ❑ Dispenser Containment Floats and Chain (s). ❑ Dis enser 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): El System set-up 21 Alarm history report Technician Name(print): Al Milburn Signature: 0—. Certification No.: A27843 License.No.: 90-1409 (CA tank test license) Testing Company Name: EPIC Compliance Systems, LLC Phone No.: 888-700-EPIC Testing Company Address: 1435 Huntington Ave, Suite 230 South San Francisco, CA 94080 Date of Testing/Servicing: 1/5/2011 UN-036-1/4 Page 1 of 4 Rev.06/04/01 www.unidocs.org