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MONITORING SYSTEM CERTIFICATIORECEIVED 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 C Rf 6yumWs This form must be used to document testing and servicing of monitoring equipment.A separate certification or re ort must be prepared for each monitoring system control panel by the technician who performs the work. A copy of this f t�tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating 4'Q6 30 days of test date. A. General Information Facility Name: New Cingular Wireless PCS,LLC dba AT&T Mobility GeoPar#: USID92230 Site Address: 6855 W Eight Mile Rd City: Stockton Zip: 95219 Facility Contact Person: .Jody Rhoades Phone: (925)288-9898 Make/Model of Monitoring System: Veeder Root TLS-350 Date of Testing/Servicing: 1/13/11 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: USID92230 A001 Tank ID• M In-Tank Gauging Probe. Model: _847390-101 ❑ In-Tank Gauging Probe. Model: ®Annular Space or Vault Sensor. Model:pa025911449 ❑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: M Tank Overfill/High-Level Sensor. Model: _790091-001 El Tank Overfill/High-Level Sensor. Model: M Other(specify equipment a and model in Section—E on Pae 2). ❑Other(specify equipment a 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(specify equipment a and model in Section E on Page 2). ❑Other(specify equipment tye and model in Section E on Pae 2). 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 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). I ❑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): M System set-up M Alarm history report Technician Name(print): Raul Ochoa Signature: ROXAY gkL__ Certificatio No.: B34397 License.No.: 734854 Testing Company Name: California Hazardous Services,Inc. Phone: (714)434-9995 Testing Company Address: 2205 S.Yale St.Santa Ana,CA 92704 Date of Testing/Servicing: 1-13-11 Page 1 of 3 11/06