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ONITOING SYSTEM CERTIFICATION 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. e apar ste certification or report must pnpa.�� far each tnontorins 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 Bldg. No.: Site Address: 13850 DeVjjr.9 Road City: Lodi Zip: 95242 Facility Contact Person:. Gary Duvall Contact Phone No.: 209-985-0843 Make/Model of Monitoring System: TMS 2QM Pneu Mercator Date of Testing/Servicing: 09_ / 2049 B. Inventory of Equipment Tested/Certified Tank ID: ® In -Tank Gauging Probe. lg1 Annular Space or Vault Sensor. EM Piping Sump / Trench Sensor(s). ❑ Fill Sump Sensor(s). ❑ Mechanical Line Leak Detector. O Electronic Line Leak Detector. ® Tank Overfill / High -Level Sensor, Tank ID: ❑ In -Tank Gauging Probe. ❑ Annular Space or Vault Sensor. ❑ Piping Sump / Trench Sensor(s). Cl Fill Sump Sensor(s). O Mechanical Line Leak Detector. ❑ Electronic Line Leak Detector. ❑ Tank Overfill / High -Level Sensor ❑ Other (specify equipment type and Dispenser ID: ❑ Dispenser Containment Sensor(s). ❑ Shear Valve(s). Dispenser ID: ❑ Dispenser Containment Sensor(s). ❑ Shear Valve(s). Model: _ MP 450 Model: LS 7A Model: L5 600 Model: Model: Model: Model: RA 200 todel in Section E on Page 2). Model: Model: Model: Model: Model: Model: Model: model in Section E on Page 2}. Model: Model: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). O D' Containment Floats) and Chain( Tank ID: ❑ In -Tank Gauging Prof. ❑ Annular Space or Vault Sensor. ❑ Piping Sump / Trench Sensor(s). ❑ Fill Sump Sensor(s). ❑ Mechanical Line Leak Detector. ❑ Electronic Lane Leak Detector. ❑ Tank Overfill / High -Level Sensor. n (lrh" (cnrrifv enuinment tvne and Tank ID: El In -Tank Gauging Probe. 13 Annular Space or Vault Sensor. ❑ Piping Sump / Trench Sensor(s). ❑ Fill Sump Sensor(s). ❑ Mechanical Line Leak Detector. ❑ Electronic Line'Leak Detector. ❑ Tank Overfill / High -Level Sensor. 13 other (specify equipment type and n Model: Model: Model: Model: Model: Model: Model: Dispenser ID: ❑ Dispenser Containment Sensor(s). ❑ Shear Valve(s). ElDis ensu Containment Floats and Dispenser ID: O Dispenser Containment Sensor(s). ❑ Shear Valve(s). n rlicnam" rnntainment Floatfs) and Dispenser ID: ❑ Dispenser Containment Serwr(s). ❑ Shear Valve(s). E on Model: Model: Model: Model: Model: Model: Model: todel in Section E on Page 21. Model: Chains . Model: Model: ispenser *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): O System set-up I@ Alarm history report Technician Name (print): Keith Huston Certification No.: _ A25577 Testing Company Name: EPIC_ Compliance Systems. LLC Testing Company Address: 100. Bavhill Df. Suite 150 UN -036 - ria Page 1 of 4 Signature: www.unidocs.ore License. No: 880430 Phone No.: 888 -700 -EPIC Date of Testing/Servicing: 0 /1612009 Rev. 06/04/01