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MONI RING SYSTEM CERTIFIOATION 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: Verizon Site Address: 13850 Devries Road Facility Contact Person: Jonathan Pakele / Paul Make/Model of Monitoring System: TMS 2000 Pneumercator B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Bldg. No. — City: Lodi, CA Zip: 95242 Contact Phone No: 559-217-6719 Date of Testing/Servicing: 9/14/2011 Tank ID: 1 — Diesel Tank ID: Q In -Tank Gauging Probe. Model: M P450 ❑ In -Tank Gauging Probe. Model: Q Annular Space or Vault Sensor. Model: LS610 ❑ Annular Space or Vault Sensor. Model: Q Piping Sump / Trench Sensor(s). Model: LS600 ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: a 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: Q Other (specify ui ment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 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: ❑ Others eci equipment a and model in Section E on Pa e 2). ❑ Other (Tecify equipment type and model in Section E on Pa e 2). Dispenser ID: --- Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dis enser Containment Floats and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float s) and Chain(s). ❑ Dispenser Containment Floats and Chains . Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ 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/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): 21 System set-up 21 Alarm history report Technician Name (print) Certification No: Alvin L. Milburn 10711 Testing Company Name: EPIC Compliance Systems Inc. Signature: License No. 956593 Phone No. 888 -700 -EPIC r Testing Company Address: 1435 Huntington Ave, Suite 230 South San Francisco, CA 94080 Date of Testing/Servicing: 9/14/2011 UN -036 -1/4 Page 1 of 4 Rev. 06/04/01 www.unidoes.org