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ONI RING SYSTEM CERTIF _.ATION VMS 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 pared 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: Teichert Bldg.No.: Site Address: 120 Frank West Circle City: Stockton Zip: 95206 Facility Contact Person: Steve Schauman Contact Phone No.: 916-386-3767 Make/Model of Monitoring System: V/R TLS 350 Date of Testing/Servicing: 09/25/2009 B. Inventory of Equipment Tested/Certified Check t e appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: # 1 Diesel Tank ID: # 3 Waste Oil ❑X In-Tank Gauging Probe. Model: MAG-1 ❑x In-Tank Gauging Probe. Model: MAG-1 ®Annular Space or Vault Sensor. Model: 794380-409 ®Annular Space or Vault Sensor. Model: 794380-407 ❑x Piping Sump/Trench Sensor(s). Model: 794380-208 ®Piping Sump/Trench Sensor(s). Model: 794380-208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: El Electronic Line Leak Detector. Model: 848480-001 ❑ Electronic Line Leak Detector. Model: IM Tank Overfill/High-Level Sensor. Model: 790095-001 O Tank Overfill/High-Level Sensor. Model: 790095-001 ❑ Other(speciLy equipment t e and model in Section E on Pae 2). ❑ Other(specify equipment t e and model in Section E on Pae 2). Tank ID: # 2 Unleaded Tank ID: ❑x In-Tank Gauging Probe. Model: MAG-1 ❑ In-Tank Gauging Probe. Model: 0 Annular Space or Vault Sensor. Model: 794380-409 ❑ Annular Space or Vault Sensor. Model: El Piping Sump/Trench Sensor(s). Model: 794380-208 ❑ 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: IEI Electronic Line Leak Detector. Model: 848480-001 ❑ Electronic Line Leak Detector. Model: M Tank Overfill/High-Level Sensor. Model: 790095-001 ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment a and model in Section E on Page 2). ❑ Other(specify equipment t e and model in Section E on Page 2). Dispenser ID: 1/ 2 Dispenser ID: O Dispenser Containment Sensor(s). Model: 794380-208 ❑ 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: 3/ 4 Dispenser ID: El Dispenser Containment Sensor(s). Model: 794380-208 ❑ 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). ❑ Dispenser Containment Float(s)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): x❑ System set-up O Alarm history report Technician Name(print): Keith Huston Signature: {` Certification No.: A25577 License.No.: 880430 Testing Company Name: EPIC Compliance Systems, LLC Phone No.: 888-700-EPIC Testing Company Address: 1001 Bayhill Dr, Suite 150 Date of Testing/Servicing: 09/25/2009 UN-036-1/4 Page 1 of 4 Rev.06/04/01 www.unidoes.org