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t � MON14UNG SYSTEM CERTIFI TION 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 perforn s 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: PAC BELL dba AT&T CALIFORNIA Geo Par#: UE020 CLLC Code: LODICA01 Site Address: 124 W.ELM STREET City: LODI Zip: 95240 Facility Contact Person: CONNIE MITCHELL Contact Phone No.: (209)474-4022 Make/Model of Monitoring System: VEEDER ROOT TLS 350 PLUS Date of Testing/Service: 07/05/07 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate s ecific equipment ins ected/serviced: Tank ID: TANK# 1214 Tank ID: ®In-Tank Gauging Probe Model: 847390-107 ❑In-Tank Gauging Probe: Model: ®Annular Space or Vault Sensor: Model: 794390-420 ❑Annular Space or Vault Sensor Model: ®Piping Sump/Trench Sensor(s): Model: 794380-352 ❑Piping Sump/Trench Sensor(s): Model: Will Sump Sensor(s): Model: 794380-352 ❑Fill Sump Sensor(s): Model: []Mechanical Line Leak Detector. Model: N/A ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector Model: N/A ❑Electronic Line Leak Detector Model: []Tank Overfill/High-level Sensor: Model: 790091-001 ❑Tank Overfill/High-level Sensor: Model: ®Other, Specify equip.type and model in Section E on Page 2 ❑Other,Specify equip.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. a and model in Section E on Page 2 []Other, Specify equip. e 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 Valve(s). ❑Dis enser Containment Float(s)and Chain(s) ❑Dis enser 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). ❑Dis enser 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). ❑Dis enser Containment Float(s)and Chain(s) ❑Dis enser 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): ❑x System set-up ❑x Alarm history report Technician Name(Print): MICHAEL STRAWN Signature: _ �� Certification No.: A31215 License No.: 588098 Testing Company Name: TAIT ENVIRONMENTAL SERVICES Phone No.: (714)560-8222