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MONITORING SYSTEM CERTIFICATION � dc 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 pan F "� � rforms the work. A copy of this form must be provided to the tank system owner/operator. The owner/op t1s� � of this form to the local agency regulating UST systems within 30 days of test date. A. General Information � � 7�a$ Facility Name: Nick's Shell � il1Q i,i�Iig" gyp; Bldg.No.: Site Address: 16500 Harland r" C4'ii US'ERVICES City: Lathrop, CA Zip: 95330 Facility Contact Person: Chris Contact Phone No.: Make/Model of Monitoring System: Veeder Root TLS 350 Date of Testing/Servicing: 11/21/08 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: T-1 91 Tank ID: El In-Tank Gauging Probe. Model: MAG 1 ❑ In-Tank Gauging Probe. Model: ❑x Annular Space or Vault Sensor. Model: 409 ❑ Annular Space or Vault Sensor. Model: ❑X Piping Sump/Trench Sensor(s). Model: 208 ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Fxl Mechanical Line Leak Detector. Model: 99 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: ❑ Other(specify equipment a and model in Section E on Page 2). R ❑ Other(specify equipment a and model in Section E on Pe 2). Tank ID: T-2 87 Tank ID: 0 In-Tank Gauging Probe. Model: MAG 1 ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: El Piping Sump/Trench Sensor(s). Model: 208 ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑X Mechanical Line Leak Detector. Model: 99 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: ❑ Other(specify equipment a and model in Section EonPae 2). ❑ Other(specify equipment tye and model in Section E on Pae 2 . Dispenser ID: 1-2 Dispenser ID: 7-8 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: FXI Shear Valve(s). ElShear Valve(s). ❑x Dispenser Containment Float(s)and Chain(s). ©Dispenser Containment Floats and Chain(s). Dispenser ID: 3-4 Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Il Shear Valve(s). ❑ Shear Valve(s). El Dispenser Containment Floats and Chain(s). I ❑ Dispenser Containment Floats and Chain(s). DispenserlD: 5-6 Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑x Shear Valve(s). ❑ Shear Valve(s). ElDispenser Containment Floats and Chain(s). ❑ Dispenser Containment Float(s)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): O System set-up ❑x Alarm history report e s Technician Name(print): Alvin 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: 11/21/08 ITN-036-1/4 Page 1 of 4 Rev.06/04/01 www.unidoes.org