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Appendix V1 (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.waterboards kr4g MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California -Chapter 6.7,Health and "J" Safety Code;Chapter 16,Division 3, Title 23,California Code afRegulations Authority Cited. V I- Thisform must be used to document testing and servicing of monitoring equipment.A separate certification or report must be prepared for each z1 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 Telephone Co. dba AT&T California Building No.: UE020 Site Address: 124 W. ELM ST. City: Lodi Zip: 95240 Facility Contact Person: Thuy Tran Contact Phone No.: (209)474-4022 Make/Model of Monitoring System: Veeder Root TLS 350 Plus Date of Testing/Servicing: 3/12/2015 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: - —-------------- . ........ ------ �=r........................ ................= Tank ID: UE020U001 Tank ID: UE020A003 F" In-Tank Gauging Probe. Model: 847390-107/439514 F In Jank Gauging Probe. Model: � Annular Space or Vault Sensor. Model: 794390420/441672 F_1' Annular Space or Vault Sensor. Model: 794380-344/844409 fl—l' Piping Sump/Trench Sensor(s). Model: 794380-208/685112 F Piping Sump/Trench Sensor(s). Model: F Fill Sump Sensor(s). Model: 794380-208/657586 Fill Sump Sensor(s). Model: F Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: F Electronic Line Leak Detector. Model: F Electronic Line Leak Detector. Model: W1 Tank Overfill/High-Level Sensor. Model: 790091-001 r 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: I F In-Tank Gauging Probe. Model: In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: F Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: F Piping Sump/Trench Sensor(s). Model: F Fill Sump Sensor(s). Model: F Fill Sump Sensor(s). Model: F Mechanical Line Leak Detector. Model: F Mechanical Line Leak Detector. Model: ii F Electronic Line Leak Detector. Model: F Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: F Tank Overfill/High-Level Sensor. Model: F Other(specify equipment type and model in Section E on Page 2). Other(specify equipment type and model in Section E on Page 2). ____.......... "I.......... Dispenser ID: i Dispenser ED: Dispenser Containment Sensor(s). Model: r— Dispenser Containment Sensor(s). Model: F Shear Valve(s). F Shear Valve(s). F Dispenser Containment Float(s)and Cbain(s). F Dispenser Containment Float(s)and Chain(s). ............... Dispenser ID: Dispenser ID: Dispenser Containment Sensor(s). Model: F Dispenser Containment Sensor(s). Model: ShearValve(s). F Shear Valve(s). F Dispenser Containment Float(s)and Chain(s). F Dispenser Containment Float(s)and Ch ain(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) P System set-up W Alarm history report Technician Name(print): Dan Luck OcIr Signature: X&O-Z 1140,1104, 40" Certification No.: B35802 License.No.: 588098 Testing Company Name: TAIT ENVIRONMENTAL SERVICES Phone No.: 714560-8222 Testing Company Address: 2131 SOUTHDUPONT DRIVF AMAHEIM,CA92806 Date of Testing/Sery icing: 3/12/2015