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MONITORING SYSTEM CERTIFICATION 0l�1IC For Use By All Jurisdictions Within the State of California ns .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 re ared 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: Charter Way Chevron Bldg'No.. Site Address: 508 Charter Way City: _Stockton. CA Zip: 95206 Facility Contact Person: Maria _ Contact Phone No.:209-465-3440 Make/Model of Monitoring System: VR-350 R Date of Testing/Servicing: 10/22/08 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates ecific equipment ins ected/scrviced: tank ID: 3-Diesel Tank ID: 1-87 0 In-'rank Gauging Probe. Model: MAG-1 ® In-Tank Gauging Probe. Model: MAG-1 l]Annular Space or Vault Sensor. Model: 794390-420 l]Annular Space or Vault Sensor. Model: 794390-420 El Piping Sump/Trench Sensor(s). Model: 794380-208 ®Piping Sump/Trench Sensor(s). Model: 794380-208 ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: CIX.. Electronic Line Leak Detector. Model: PLLD ll Electronic Line Leak Detector. Model: PLLD ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill 1 High-Level Sensor. Model: ❑ Other�specifX equipment t e and model in Section E on Pae 2). ❑ Other�specifj a ui ment a and model in Section E on Pa«c 2). Tank ID: 2-91 Tank ID: _ ❑X In-Tank Gauging Probe. Model: MAG-1 ❑ to-Tank Gauging Probe. Model: _ Q Annular Space or Vault Sensor. Model: 794390-420 ❑ Annular Space or Vault Sensor. Model: ®Piping Sump/Trench Sensor(s). Model: 794380-208 ❑ 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: _ EI Electronic Line Leak Detector. Model: PLLD ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify a ui ment tXpe and model in Section E on Pae 2). Dispenser ID: 1-2 Dispenser ID: 7-8 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Scnsor(s), Model: 0 Shear Valve(s). (El Shear Valve(s). NI Dispenser Containment Floats and Chain(s). El Dispenser Containment Floats and Chain(s). Dispenser ID: 3-4 Dispenser ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s), Model: E Shear Valve(s). ❑ Shear Valve(s). ❑X Dis enser Containment Floats and Chain(s' . ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5-6 Dispenser ID: 13 Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: I]Shear Valve(s). ❑ Shear Valve(s). ❑X Dis enser Containment 1,loat(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/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,1 have also attached a copy of the report;(check all that apply): X❑ System set-up ❑X Alarm history report Technician Name(print): Alvin L. Milburn _ Signature: Certification No.: A27843 License.No.: 880430 Testing Company Name: EPIC Compliance Systems, Inc. Phone No.: 888-777-EPIC Testing Company Address: _2400 San Bruno Ave, San Francisco, CA Date of Testing/Servicing: 10/22/08 UN-036-1/4 Page 1 of 4 Rev.06/04101 www.unidoes.org