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ONI NG SYSTEM CETIF ATION 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: PACIFIC BELL GEO PAR # UE -046 CLLC Code: sKTNCAt t Site Address: 907 LINCOLN ROAD City: STOCKTON Zip: Facility Contact Person: KATHY HALLIGAN Contact Phone No.: 209-474-4514 Make/Model of Monitoring System: VEEDER-ROOT TLS -350 Date of Testing/Service B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: 8/12/03 Tank ID: 1171 Tank ID: ZIn-Tank Gauging Probe: Model: 847390-106 ❑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: 794380-352 ❑Piping Sump/Trench Sensor (s): Model: ®Fill Sump Sensor (s): Model: 794380-352 ❑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 Overfill/High-level Sensor: Model: ❑Other, Specify Sq!! i . e and model in Section E on Page 2 ❑Other, Specify equip. e and model in Section E on Pa e 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. type and model in Section E on Page 2 ❑Other, Specify e ui .e 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). []Dispenser Containment Float(s) and Chain(s) ❑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). ❑Dis enser Containment Float(s) and Chain(s) ❑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) ❑Dis enser 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. 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): Z System set-up Z Alarm history reort Technician Name (Print): FRED RIDDLES Signature: (j) �,['1�1 _ Certification No.: 9579 License No.: 588098 Testing Company Name: TAIT ENVIRONMENTAL SYSTEMS Phone No.: (714) 560-8222