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} 't Appendix VI (Copies of Monitoring System Certification form and LIST Monitoring Plot Plan available at http://www,waterboards.ca,gov) Monitoring System Certification For Use By All Jurisdictions Within the State of Califomia 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 ownerloperator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility: Pacific Bell Telephone Co.dba AT&T California GEO PAR#UE020 Address: 124 W. ELM ST. City: LODI Zi : 95242 Facili Contact Person: Connie Mitchell Contact Phone No:209-474-4022 Make/Model of Monitoring System:Veeder Root TLS-350 Service Date: 12/04/2009 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment Inspectedlserviced: Tank ID:UE020U001 Tank ID: ®In-Tank Gauging Probe Model:847390-107 ❑In-Tank Gauging Probe Model: ❑Annular Space or Vault Sensor Modek ❑Annular Space or Vault Sensor Model: ❑Piping Sump/Trench Sensor(s) Model: ❑Piping Sump/Trench Sensor(s) Model: ❑Fill Sump Sensor(s) Model: Q Fill Sump Sensor(s) Model: ❑Mechanical Line Leak Detector Model: ❑Mechanical Line Leak Detector Model: ❑Electronic Line Leak Detector Model: ❑Electronic Line Leak Detector Madel: ®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) ❑OtherS eci ( p fy 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: Q 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 tine 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 p type and model in Section E on Page 2) Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensor(s) Model: ❑Dispenser Containment Sensor(s) Model: ©Shear Valve(s) ❑Shear Vafve(s) ❑Dispenser Containment Float(s)and Chain(s) ❑Dispenser Containment Float(s)and Chain(s) Dispenser ID: DIsDenserID: ❑Dispenser Containment Sensor(s) Model: ❑Dispenser Containment Sensor(s) Model: ❑Shear Valve(s) Q Shear Valve(s) ❑Dispenser Containment Float(s)and Chain(s) ❑Dispenser Containment Float(s)and Chaln(s) DispenserlD: _Dispenser ID: ❑Dispenser Containment Sensors) 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) 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 Piot 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 ®Alarm history report Technician Name(Print): John Cascio Si nature: Certification No: B35337 I License No 88098 Testing Company Name:TAIT ENVIRONMENTAL SERVICES -'✓ Phone No: 714 560-8222 Testing Company Address:2131 South Dupont Drive Anaheim CA 92806 1 Date of Testin Servicin : 12/04/2009 Monitoring System Certification Page 1 of 4 12/07 1 2121/07