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w MONITORING SYSTEM CERTIFICATION EPAC For Use By All Jurisdictions Within the State of California MAY 2 7 2008 Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, Cal,ifornia Cod FpfRgg�lgtigrys MTWONO01_IV I tit T It This form must be used to document testing and servicing of monitoring equipment. A separate r rt 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: Gas Depot (Shell) Bldg.No.: Site Address: 824 E. Yosemite Ave City: Manteca. CA Zip: 95336 Facility Contact Person: John Contact Phone No.: (209) 825-7722 Make/Model of Monitoring System: G. LBARCO EMC Date of Testing/Servicing: 04/23/08 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: TanklD: 1-87 TanklD: 3-91 O In-Tank Gauging Probe. Model: MAG-2 O In-Tank Gauging Probe. Model: MAG-2 W Annular Space or Vault Sensor. Model: PA02591144000 O Annular Space or Vault Sensor. Model: PA02591144000 -91 Piping Sump I Trench Senscr(s). Model PA02592000000 O Piping Sump/Trench Sensor(s). Model: PA0259 ❑ Fill Sump Sensor(s). Model ❑Fill Sump Sensor(s). Model: O Mechanical Line Leak Detector. Model: LD 2000 0 Mechanical Line Leak Detector. Model LD 2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Ove�ll/High-Level Sensor. Model: ❑ Other�spccify a ui ment and model in Section E on Pae 2). 0 Other(specify equipment type and model in Section E on Page 2). Tank ID: 2 — 89 TanklD: Ul In-Tank Gauging Probe. Model: MAG-1 ❑ In-Tank Gauging Probe. Model: O Annular Space or Vault Sensor. Model: PA02591144000 ❑ Annular Space or Vault Sensor. Model: ®Piping Sump/Trench Sensor(s). Model: PA02592000000 ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: M Mechanical Line Leak Detector. Model: LD 2000 ❑ 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: 0 Other(specify equipment a and model in Section E on P e 2 . ZI Other(specify equipment type and model in Section E on Page 2). Dispenser ID: 1-2 Dispenser ID: 7-8 0 Dispenser Containment Sensor(s). Model: 794380-322 O Dispenser Containment Sensor(s). Model: 794380-322 0 Shear Valve(s). ©Shear Valve(s). ❑ Dispenser Containment Floats and Chains . ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: 3-4 Dispenser ID: 171 Dispenser Containment Sensor(s). Model: 794380-322 ❑ Dispenser Containment Sensor(s). Model: 17 Shear Valve(s). ❑ Shear Valve(s). Q Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5-6 Dispenser ID: 0 Dispenser Containment Sensor(s). Model: 794380-322 ❑ Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). ❑ Shear Valve(s). ❑ Dis22nser Containment Floats 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,I have also attached a copy of the report;(check all that apply): O System set-up 171 Alarm history report Technician Name(print): Alvin L. Milburn Signature: �y"�"" Certification No.: A27843 License.No.:880430 Testing Company Name: EPIC Compliance Systems Inc. PhoneNo.: 888-777-EPIC Site Address: 824 E. Yosemite Ave Manteca. CA Date of Testing/Servicing: 04/23/08 UN-036-1/4 Page 1 of 4 Rev.06/04/01 www.unidocs.org