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Appendix V1 (Copies of Monitoring System Certification form and LIST Monitoring Plot Plan available atca.gov .) MONITORING SYSTEM CERTIFICATION MAR 15 2016 For Use By All Jurisdictions Within the State of California Authority Cited:Chapter 6.7,Health and Safety Co de;Chapter 16,Division 3, Title 23,California Code ofRegulationENVIRONMENTAL This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be 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 ov,ner/operator must submit a copy o f this form to the local agency regulating LIST systems within 30 days of test date. 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: 03-01-2016 B. Inventory of Equipment Tested/Certi tied Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: UE0200001 1! Tank ID: UE020A003 In ❑In-Tank Gauging Probe. Model: PFX -Tank Gauging Probe. Model: 847390-107/439514 1z X Annular Space or Vault Sensor. Model: 794390-420/441672I Annular Space or Vault Sensor. Model: 794380-344 844409 Fx JIN Piping Sump/Trench Sensor(s). Model: 794380-208/685112 ❑Piping Sump/Trench Sensor(s). Model: Fill Sump Serisor(s). Model: 794380-208/657586 1❑Fill Sump S sor(s). Model: Ej F-1 Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ii Electronic Line Leak Detector. Model F❑-1'IElectronic Line Leak Detector. Model:F❑1 FX� Tank Overfill/High-Level Sensor. Model: 790091-001 Tank Overfill/High-Level Sensor. Model: 1 Other(specify equipment type and model in Section E on Page 2).1FX Other(specify equipment type and model in Section E on Page 2). Tank ID- Tank ID: II❑ In-Tank Gauging Probe. Model: ❑In-Tank G augging Probe. Model: H❑ Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: ij Piping Sump/Trench Sensor(s). Model: I E ❑Piping Sump/Trench Sensor(s). Model: I F-1 Fill Sunip Sensor(,). Model: ❑Fill Sump Sensor(s). Model: ppppl 1❑ Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: IF-1 Electronic L ine Leak Detector, Model: Electronic Line Leak Detector. Model: ❑ Tank Overfill/Fligh-Level Sensor. Model: 11❑Tank Overfill/High-Level Sensor. Model: Other(specify equipment type and model in Section E on Page 2). 110 Other(speci6,equipment type and model in Section E on Page 2). S-_-----------_------ 'T...... Dispenser ID: Dispenser IDii I: Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: ii Shear Valve(s). ❑Shear Valve(s). Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Ch ain(s). ...........� -------.............I'll, ............ I Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: i❑Dispenser Containment Sensor(s). Model: Shear Valve(s). Shea,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 set 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 tha t apply) : M�I I System set-up Z Alarm history report Technician Name(print): John Cascio Signature: _ �Wa &dda Certification No.: B35337 License. No.: 588098 Testing Company Name: TAIT ENVIRONMENTAL SERVICES Phone No.: 714560-8222 Testing Company Address: 2131 SOUTH DUPONT DRIVE,ANAHEIM,CA92806 Date of Testing/Servicing: 03-01-2016