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08/19/2008 09: 25 8316481924 SPECIAL SERVICES PAGE 02 0 0 Monitoring System Certification For Use By AB Jurisdictions Krithfn the State of Catifomia Author/fy Cited:Chapter 6.7,Health and Safety Code;Chapter 16,Division 3, rt/e 23, Callfornia Code or Regulations This form must be used to document testing and servicing of monitoring equipment A rate certification or report must be prepared for each monitoring system a4ntr�panel by the tadmicien why pertomms the work.A COPY ofprovided o system owns or.The Owner opera r Copy of this form to the local agency regulating UST systems within Be30 days of test date. A. General Information Facility! Pacific Belf Telephone Co. dba AT&T California GEO PAR#UE020 Address. 124 W. ELM ST. Citv. LODI Zi :95242 FacilityContact Person: CONNIE MITCHELL E.S.M. Contact Phone No: 209-474-4022 Make/Model of Monitoring System:VIEWER ROOT TLS-350 Service Date:07/30/2008 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID:#UE0200001 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 Sensors) Model: ❑Fill Sump Sensor(s) Model: El Mechanical lane Leak Detector Model: ❑Mechanical Line Leak Detector Model: ❑Electronic Ltne Leak Detector Madel; ❑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) 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 Sansor(s) Model; ❑Fill Sump Sensor(s) Made]; [�Mechanical Line Leak Detector Model: ❑Mechanical Line Leak Detector Model: ❑Electronic Line leak Detector Model: [3 Ela, ronlc 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 Sensor(a) Model; ❑Dispenser Containment Sensor(s) Model: ❑Shear Valve(s) ❑Shear Valve(s) ❑Dispenser Containment Float(s)and Chaln(s) ❑Dispenser Containment Floats)and Chain(s) Dispenser ID, DispenserlD: 0 Dispenser Containment Sensors) Model; ❑Dispenser Containment Sensor(s) Model: ❑Shear valve(s) _ ❑Shear Valve(s) ❑Dispenser Containment Float(s)and Chalt(s) ❑Dispenser Containment Float(s)and Chain(s) Di enserID: Dispenser ID: ❑Dispenser Containment Sensoria) Model: ❑Dispenser Containment Sensor(s) Model: 0 Shear Valve(s) _ __ ❑Shear Valve(s) ❑Dispenser Containment Float(s)and Chains) ❑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 infomratlon(e.g.manufacturers'checklists)necessary to verify that this Information is correct and a Plot Plan showing the layout of monitoring eqlul went.For any equipment capable of generating such reports,t have also attached a copy of the report;(check all that apply): _ Al2rrn history report Technician Name(Print): MICHAEL L.STRAWN it Si nature- Certification No:VEEDER ROOT-A31215 License o:588098 Testing Company Name:TAIT ENVIRONMENTAL Phone No:(714)560-8222 SERVICES Page 1 of 4