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M MONITORING SYSTEM CERTIFICATI z For Use By All Jurisdictions Within the State of CaliforniaENvl RON ENT HEALVE �a Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, Cal tions 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 appropriate boxes to indicatespecific equipment inspected/serviced: Tank 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/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/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Others eci equipment t e and model in Section E on Pa e 2). ❑ Other(s2eciLy equipment t e and model in Section E on Pae 2). Tank 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/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/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specia a ui ment type and model in Section E on Pae 2 . ❑ Other(s2ecify a ui ment type and model in Section E on Pa e 2). Dispenser ID: 12-13S Dispenser ID: 13-14S ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). I@ Shear Valve(s). ❑O Dis enser Containment Floats and Chains . ©Dispenser Containment Floats and Chain(s). Dispenser ID: 14-15S Dispenser ID: 15-16S ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: 1XI Shear Valve(s). IR Shear Valve(s). 1l Dispenser Containment Floats and Chains . IRl Dispenser Containment Floats and Chain(s). Dispenser ID: 16-17S Dispenser ID: 17-18 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ©Shear Valve(s). O Shear Valve(s). 91 Dispenser Containment Floats and Chains . IM Dispenser 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): El Sysi sort s Technician Name(print): Keith Huston Signature: Certification No.: A25577 License.No.: 880430 Testing Company Name: EPIC Compliance Systems, Inc. PhoneNo.: 888-700-EPIC Testing Company Address: 2400 San Bruno Ave, San Francisco, CA Date of Testing/Servicing: UN-036-1/4 Page 1 of 4 Rev.06/04/01 www.unidocs.org