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MONIT NG SYSTEM CETIFI ION For Use By All Jurisdictions Within the State of California luthority Cited.• Chapter 6.7. Health and Sgfety Code; Chapter 16, Division 3. Title 23, California Code of Re illations * 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: PACBELL DBA AT&T CALIFORNIA GEO PAR# UE020 CLLC Code: t•oDicnoi Site Address: 124 W. ELM STREET City: LODI Zip: Facility Contact Person: CONNIE MITCHEL Contact Phone No.: 209-474-4022 Make/Model of Monitoring System: VEEDER-ROOT TLS-350 Date of Testing/Service: 03-16-2007 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: 1214 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: 794380-208 ❑Piping Sump/Trench Sensor(s): Model: ®Fill Sump Sensor(s): Model: 794380-208 []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 equip.type and model in Section E on PaLe 2 []Other, Specify equi .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 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 equip.ty e and model in Section E on Page 2 ❑Other, Specify equip.tye and model in Section E on Pa��e 2 Dispenser 1D: Dispenser ID: ❑Dispenser Containment Sensor(s): Model: ❑Dispenser Containment Sensor(s): Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Float(s)and Chain(s) I []Dispenser Containment Float(s)and Chain(s) Dispenser ID: Dispenser 1D: [-]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). I ❑ 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 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 ® Alarm history report Technician Name(Print): John Cascio Signature: Certification No.: B35337 License No.: 588098 t Testing Company Name: TAIT ENVIRONMENTAL SERVICES Phone No.: (714)560-8222