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4 MONIT,tING SYSTEM CERTIFI .-ATION 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: PACIFIC BELL GEO PAR# UE-R47 CLLC Code: SKTNCAI6 Site Address: 4051 NEWTON ROAD City: STOCKTON Zip: Facility Contact Person: CONNIE MITCHELL Contact Phone No.: 209-474-4014 Make/Model of Monitoring System: VEEDER-ROOT TLS-350 Date of Testing/Service: 8/9/02 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment ins ted/serviced: Tank ID: 2029 Tank ID: ®In-Tank Gauging Probe: Model: 847390-107 ❑ht-Tank Gauging Probe: Model: ®Annular Space or Vault Sensor: Model: 794390-420 ❑Annular Space or Vault Sensor Model: ®Piping Sump/Trench Sensor(s): Model: 794390-205 ❑Piping Sump/Trench Sensor(s): Model: ®Fill Sump Sensor(s): Model: 794390-205 []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 ui and model in Section E on Page 2 ❑Other, Specify ui 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 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 ui . type and model in Section E on Pa e 2 ❑Other,Specify equip. a and model in Section E on Page 2 Dispenser ID: Dispenser ID: ®Dispenser Containment Sensor: Model: 794390-420 ❑Dispenser Containment Sensor(s): Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Floats and Chains ODispenser Containment Floats and Chain(s) Dispenser ID: Dispenser ID: ❑In-Tank Gauging Probe: Model: ❑Dispenser Containment Sensor(s): Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Floats and Chains ❑Dis eraser Containment Floats and Chain(s) Dispenser ID: Dispenser ID: ❑In-Tank Gauging Probe: Model: ❑Dispenser Containment Sensor(s): Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ODispenser Containment Floats and Chain(s) ❑Dis ser 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): ® System set-up ® isto report Technician Name(Print): FRED RIDDLES Signature: C�,((JJ Certification No.: 9579 License No.: 588098 Testing Company Name: TAIT ENVIRONMENTAL SYSTEMS Phone No.: (714)560-8222 Page 1 of 3 03101