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MONITILNG 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 mast 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 mist 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 #: CAK482 Site Address: 110 WEST TURNER ROAD City: LODI Facility Contact Person: CONNIE MITCHELL Contact Phone No. Make/Model of Monitoring System: VEEDER ROOT TLS 300 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: CLLC Code: LODICA02 Zip: 95240 (209) 474-4022 Date of Testing/Service: 07/13/07 Tank ID: DIESEL Tank ID: ®In -Tank Gauging Probe Model: 847390-109 ❑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: 794280-208 ❑Piping Sump/Trench Sensor (s): Model: ®Fill Sump Sensor (s): Model: 794280-208 ❑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. a and model in Section E on Page 2 ❑Other, Specify equip. a 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. t e and model in Section E on Page 2 ❑Other, Specify equi a 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 Chains ❑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 Chains ❑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). []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. Certiflcation - 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): 0 System set- i istory report Technician Name (Print): MICHAEL STRAWN Signature: 16— Certification No.: A31215 License No.: 588098 Testing Company Name: TAIT ENVIRONMENTAL SERVICES Phone No.: (714) 560-8222