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MONI"i dRING SYSTEM CERTI&i ATION 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 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: 2500 West Turner Road City: Lodi Zip: 95242 Facility Contact Person: Gary Duvall Contact Phone No.: (209) 985-0843 Make/Model of Monitoring System: Pneumercator 2000 Date of Testing/Servicing._05/06/2009_ B. Inventory of Equipment Tcsted/Certified Check the appropriate boxes to indicatespecific a ui ment inspected/serviced: Tank ID: Diesel 'rank ID: El In-Tank Gauging Probe. Model: M P4505-088 ❑ In-Tank Gauging Probe. Model: I]Annular Space or Vault Sensor. Model: LS600 ❑ Annular Space or Vault Sensor. Model: I]Piping Sump/Trench Sensor(s). Model: LS610 (2) ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fiil 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: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment t e and model in Section E on Pae 2). 1 ❑ Other(specify equipment t e and model in Section E on Pae 2). Tank 1D: Tank ID: ❑ In-"rank 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: L7 Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: U Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill I High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(s ecifv equipment t e and model in Section E on Pae 2). ❑ Other(specify equipment tv e and model in Section E on Pae 2). Dispenser ID: --------- Dispenser 11): ❑ 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: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dis enser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chain (s). ❑ Dis enser Containment Floats and Chain (s). *Ifthe 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): ❑x System set-up 0 Alarm history report Technician Name(print): Alvin L. Milburn Signature: Certification No.: A27843 License.No.: 880430 Testing Company Name: EPIC Compliance Systems, LLC_ Phone No.: 888-700-EPIC Testing Company Address: 2400 San Bruno Ave, San Francisco, CA Date of Testing/Servicing: 05/06/2009 UN-036-l/4 Page 1 of 4 Rev.06/04/01 vvww.unidocs.org