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Ll E MONITORING 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. A separate certification or report must be prepared for earls moniWring g1stem control ®ane[ 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 Perm: Jonathan Pakele Bldg. No.: - City: Lodi Zip: 95242 Contact Phone No.: 209-235-3670 Make/Model of Monitoring System: TMS 2000 Pneumercator Date of Testing/Servicing: 09-13-2010 B. inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment is serviced: Tank ID: 1 - Diesel Tank ID: ® In -Tank Gauging Probe. Model: M4505-058 O In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: LS -610 O Annular Spare or Vault Seng. Model: 0 Piping Sump / Trench Sensor(s). Model: LS -690 O Piping Sump / Trench Sensor(s). Model: O Fill Sump Seasor(s). Model: ❑ Fill Sump Sensor(s). Model: O Mechanical Line Leak Detector. Model: O Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: O Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Seng. Model: RA -200 O Tank Overfill I High -Level Seng. Model: ® Other (REify equipment type and model in Section E on Pa 2). ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: Tank ID: ❑ In -Tank Gauging Probe. Model: O In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: O Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: O Piping Sump/ Trench Sensor(s). Model: Cl Fill Sump Sessor(s). Model: ❑ Fill Sump Sensor(s). Model: Q Mechanical Line Leak Detector. Model: O Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: O Electronic Line Leak Detector. Model: O Tank Overfill / High -Level Seng. Model: Q Tank Overfill / High -Level Seng. Model: ❑ Other i ui ment = and model in Section E on PIE 21. ❑ Other (speci& EquiEment W and model in Section E on PaIE 21. Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: O Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). O Shear Valve(s). O Di eraser Containment Flo s) and Chains . O Di&mer Containment Fj2atLsj and Chins . Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: O Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). O Shear Valve(s). ❑ Dispenser Containment Floats and Chains . O Di!Mer Containment Floats and Chains . Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: Q Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). O Shear Valve(s). ❑ Di ser Containment Flo!g!j and Chains . Q Di3= Containment Float�sj 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 (eg. 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; (cheek all that apply): ® System set-up ® Alarm history report Technician Name (print): AI Milburn Certification No.: 10711 Testing Company Name: EPIC Compliance Systems, LLC Testing Company Address: 2880 Zanker Road Suite 334 San Jose CA 95134 UN -036 -1/4 Page 1 of 4 www.unWocs.org Signature: '(w- `'/✓,✓� ,z.� License. No.: 90-1409 (CA tank test license) Phone No.: 888 -700 -EPIC Date of Testing/Servicing: 09-13-2010 Rev. 06/04/01