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RECEIVED JUN 09 2011 (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at htta:// MONITORING SYSTEM CERTIFICATION 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 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: AT & T Corporation GEOPAR: UE231 Site Address: 110 W Turner Rd. City: Lodi, CA Zip: 95242 Facility Contact Person: Connie Mitchell Contact Phone No.: (209) 474-4022 Make/Model of Monitoring System: VR TLS -350 Date of Testing/Servicing: 5/18/11 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment ins cted/serviced: Tank ID: _UE231LI001 Tank ID: ® in -Tank Gauging Probe. Model: VR 846390-109 ❑ in -Tank Gauging Probe. Model: I@ Annular Space or Vault Sensor, Model: VR 794390-420 ❑ 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: VR 790091-001 ❑ Tank Overfill / High -Level Sensor. Model: © Other (s[!2ci!y equipment type and model in Section E on Pa 2). ❑Other (specify a ui me tjype 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: ❑ Others c'y a ui ment a and model in Section E on Page 2 . Others c' equipment t e and model in Section E on Pa 2). Dispenser ID: enserlD: ❑ Dispenser Containment Sensor(s). Model: ispenser Containment Sensor(s). Model: :Dis rDispenser ❑ Shear Valve(s). hear Valve(s). ❑ Dis nser Containment Floats and Chain(s). enser Containment Floats and Chain(s). Dispenser ID: lD: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dise2nser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: Dispenser ID: 11 Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: F1 Shear Valve(s). ❑ Shear Valve(s). ❑ Disp2nser Containment Floats and Chains ❑ Disp2nser Containment Floats 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): IM System set-up ® Alarm history report Technician Name (print): Steve Parmenter Signature:, Certification No.: A28780 License. No.: 485184 Testing Company Name: _ Service Station Systems Phone No: (408) 971-2445 Testing Company Address: 680 Quinn Ave San Jose CA 95112 Date of Testing/Servicing: 5/18/11 Monitoring System Certification Page 1 of 4 12/07 2/21/07