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MONITORING SYSTEM CERTIFICATION rn% �oc For Use By All Jurisdictions Within the State of California yee l�Mc! 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 o.:_Site Address: 2500 W. Turner Road City: Lodi Zip: 95242 Facility Contact Person: Leonard Freitas Contact Phone No.: (209) 367 2628 Make/Model of Monitoring System. Pneumercator TMS 2000 Date of Testing/Servicing: 05/06/2008 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific a ui ment inspected/serviced: Tank ID: #1 3K Double Wall Fiberglass Diesel Tank ID: 0 In-Tank Gauging Probe. Model: MP-450 ❑ In-Tank Gauging Probe. Model: © Annular Space or Vault Sensor. Model.LS-610 ❑ Annular Space or Vault Sensor, Model: 0 Piping Sump 1 Trench Sensor(s). Model:LS-600 ❑ Piping Sump 1 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: 0 "tank Overfill/High-Level Sensor. Model: RA-200 ❑ Tank Overfill I High-Level Sensor. Model: ❑ Other(specify equipment a and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). `rank 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 I 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: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill I High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Pae 2). ❑ Other(specify equipment 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: ❑ 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: ]ED r ID: ❑ Dispenser Containment Sensor(s). Model: nser Containment Sensor(s). Model: ❑ Shear Valve(s). Valve(s). ❑ Dis nser Containment Float(s)and Chains . nser Containment Floats 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): 0 System set-up ©Alarm history report l Technician Name(print): Nikola Zagorov Signature: + �'�roy Certification No.: Pneumercator Certified Technician License.No.:880430 Testing Company Name: EPIC Compliance Systems Phone No.: 888-777-EPIC Address:2400 San Bruno Avenue, San Francisco, CA 94134 Date of Testing/Servicing. 05/06/2008 UN-036-114 Page 1 of 4 Rev.06AWOI www.unidoes.org