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MONITORING SYSTEM CERTIFICATION ® 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: Tracy Truck Stop Bldg.No.: Site Address: 3940 N. Tracy Blvd. City: Tracy Zip: 95304 Facility Contact Person: Debbie Contact Phone No.:—(209) 832-5006 Make/Model of Monitoring System: Date of Testing/Servicing: 03/26/2009 B. Inventory of Equipment Tested/Certified Check the approgriate boxes to indicatespecific a ui ment ins ected/serviced: Tank TD: 1 Regular/Premium Tank ID: 2 Diesel ❑O In-Tank Gauging Probe, Model: MAG-1 ❑x In-Tank Gauging Probe. Model: MAG-1 ❑x Annular Space or Vault Sensor. Model: 420 ®Annular Space or Vault Sensor. Model: 420 ❑O Piping Sump/Trench Sensor(s). Model: 208 x❑Piping Sump/Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ®Mechanical Line Leak Detector. Model: LD-2000 O Mechanical Line Leak Detector. Model: LD-2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify a ui ment type and model in Section E on Pa e Z). ❑ Other(specfty equipment t)Te and model in Section E on Pae 2). Tank ID: 3 Diesel Tank ID: ❑O In-Tank Gauging Probe. Model: MAG-1 ❑ In-Tank Gauging Probe. Model: ❑O Annular Space or Vault Sensor. Model: 420 ❑ Annular Space or Vault Sensor. Model: ❑O Piping Sump/Trench Sensor(s). Model: 208 ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ©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: ❑ Other(specify equipment t e and model in Section E on Pae 2). ❑ Other(specia equipment t e and model in Section E on Pae 2). Dispenser ID: 1-2 Dispenser ID: 3-4 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: IK Shear Valve(s). El Shear Valve(s). ®Dispenser Containment Floats and Chain(s). 21 Dispenser Containment Floats and Chain(s). Dispenser ID: 5-6 Dispenser ID: 7-8 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: I@ Shear Valve(s). ©Shear Valve(s). ❑X Dispenser Containment Floats and Chains . 0 Dispenser Containment Floats and Chains . Dispenser ID: 11S Dispenser ID: 11-12S ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ©Shear Valve(s). 21 Shear Valve(s). 19 Dis enser Containment Floats and Chain(s). ❑x Dispenser Containment Floats and Chains . *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): ©Sys1 )ort Technician Name(print): Keith Huston Signature: Certification No.: A25577 License.No.: 880430 Testing Company Name: EPIC Compliance Systems, Inc. Phone No.: 888-700-EPIC Testing Company Address: 2400 San Bruno Ave San Francisco CA Date of Testing/Servicing: 03/26/2009 UN-036-1/4 Page 1 of 4 Rev.06/04/01 www.unidocs.org