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Appendix VI \ /ED (Copies of Monitoring Systen, _deification form and UST Monitoring Plot Plan availar , at http://www. r 9Q) Monitoring System Certification DEC 0 i 2010 For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Dlvlsion 3, Title 23, Callfomfa Code of R Mations This for, must be used to document testing and servicing of monitoring equipment A separate certification or report must P L HEALTH monitoring system control panel by the technician who perforrrs the work. A copy of this form must be lo the tank sysbe iaibb!ItT6S owner/operator must submit a copy of this form to the local agency regul N UST systems within 30 days of test date. A. General Information Facility: Pacific Bell Telephone Co. dba AT&T California GEO PAR # UE656 Address: 44 W. YOKUTS ON: STOCKTON Zip: 95207.0 Facility Contact Person: Connie Mitchell Contact Phone No: 209-474-4022 Make/Model of Monitoring System: Veeder Root TLS -350 Service Date: 11/22/2010 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicate specific equipment Inspected/serviced: Tank ID: UE656AO01 Certification No: B36532 I License No: 588098 Tank ID: ® In -Tank Gauging Probe Model: 847390-105 ❑ In -Tank Gauging Probe mel. ® Annular Space or Vault Sensor Model:794390-420 ❑ Annuler Space or Vault Sensor Model: ❑ Piping Sump / Trench Sensor(s) Model: ❑ Piping Sump / Trench Sensor(s) Model: ❑ Fill Sump Sensor(s) Model: ❑ FII Sump Sensor(s) Model: ❑ Mechanical Line Leak Detector Model: ❑ Mecttanical Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: ® Tank Overfill / High Level Sensor Model:790091-001 ❑ Tank Overfill / High Level Sensor Model: ❑ Other (Specify equipment type and model in Section E on Page 2) ❑ Other (Specify equipment type and model in Section E on Page 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 Sensors) 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 (Specify equipment type and model In Section E on Page 2) ❑ Other (Specify equipment type and model in Section E on Page 2) Dispenser ID- Dispenser ID: ❑ Dispenser Containment Sensors) Model: ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valve(s) ❑ Shear Vatve(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) 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 Floats) and Chain(s) If the facility contains more tanks or dispensers, copy hs forth. Indude information for every tank and dispenser at the facility. C. Certification- I certify that the equipment identified In this document was Inspectedlserviced 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): --" set yp �Alartn history report ® �ystem Technician Name (Print): Victor Guerrero Si nature: Certification No: B36532 I License No: 588098 Testing Company Name: TAIT ENVIRONMENTAL SERVICES I Phone No: 714 560-8222 Testing Company Address: 2131 South Dupont Drive Anaheim CA 92806 1 Date of Testing/Servicing: 11/22/2010 Monitoring System Certification Page 1 of 4 12/07 1 2/21/07