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�2� MONITORING SYSTEM�`T 1 Z008�/��C For Use By All Jurisdictions Within the State of California ENS/""la �' 1 1 Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, Cale, ?O C;o t%/' u tions 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 Bldg. No.: Site Address: 13859 N Devries Road City: Lodi Zip: 95242 Facility Contact Person: Christine Lagat-Nakamori Contact Phone No.: (925) 567 6098 Make/Model of Monitoring System: Pneumercator TMS 2000 Date of Testing/Servicing: 09/16/2008 B. Inventory of Equipment Tested/Certified Check the annronriate boxes to indicate snecific eauinment insnected/serviced: Tank ID: #1 Double Wall Fiberglass Diesel Tank ID: M In -Tank Gauging Probe. Model: MP -450 ❑ In -Tank Gauging Probe. Model: RI Annular Space or Vault Sensor. Model: LS -610 ❑ Annular Space or Vault Sensor. Model: 21 Piping Sump / Trench Sensor(s). Model: LS -600 ❑ 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: 21 Tank Overfill / High -Level Sensor. Model: RA -200 ❑ Tank Overfill / High -Level Sensor. Model: 0 Other (specify equipment ty e and model in Section E on Pae 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: LlMechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: LlElectronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: LlTank Overfill / High -Level Sensor. Model: LIOther (specify equipment ty e and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). 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 Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: I ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dpenser ID: [LLJI�DispenserContainrnentSensor(s). Ll Dispenser Containment Sensor(s). Model: Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser 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/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): Rl System set-up Rl Alarm history report Technician Name (print): Nikola Zagorov Certification No.: Pneumercator Certified Technician Testing Company Name: EPIC Compliance Systems Signature: tr'ov License. No.: 880430 Phone No.: 888 -777 -EPIC Address: 2400 San Bruno Avenue, San Francisco, CA 94134 Date of Testing/Servicing:09/16/2008 UN -036 - 1/4 Page 1 of 4 Rev. 06/04/01 www.unidoes.org