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f Appendix VI (Copies of Monitoring System Certification form and USTMonitoring Plot Plan available at http://www. at b .bo F; IVE[ MONITORING SYSTEM CERTIFICATION MAR 13 2017 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 ofRegulations This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must b�yA� �-(- h�E� monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank ss em o� er to-rr. owner/operator must submit a copy ofthis form to the local agency regulating UST systems within 30 days of test date. DEe TMENT A. General Information Facility Name: Pacific Bell Telephone Co dba ATT California Facility ID: 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: 2/24/2017 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: UE0200001 Tank ID: UE020A003 ❑X hrTankGauging Probe. Model: 847390-107/439514 ❑In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 794390-420/441672 ❑X Annular Space or Vault Sensor. Model: 794380-344/844409 ® Piping Sump/Trench Sensor(s). Model: 794380-208/685112 ❑Piping Sump/Trench Sensor(s). Model: ❑X Fill Sump Sensor(s). Model: 794380-208/657586 ❑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: 790091-001 —]Tank Over /High-Level Sensor. Model: ® Other(specify equipment type and model in Section E on Page 2). ❑Other(specify equipment type and model in SectionE on Page 2). Tank ID: Tank 1D: ❑ 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: ❑Mecbanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑Electronic L ine 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(s). Model: E] Dispenser Containment Sensor(s). Model: ❑ Shear Valve(,). ❑Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑Dispenser ContainmentFloat(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sen sor(s). Model: ❑ Shear Vatve(s). ❑Shear Valve(,). ❑ Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Ftoat(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 ®Alarm history report Technician Name(print): Wes Morrison MW �LQ1YJ aaa Signature: Certification No.: b38044 License. No.: 588098 Testing Company Name: TAIT ENVIRONMENTAL SERVICES Phone No.: 714560-8222 Testing Company Address: 2131 SOUMDUPONT DRfVE ANAHEIKCA92806 Date of Testing/Servicing: 2/24/2017