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MONITAING SYSTEM CETII 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 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: sKTNCAI t Site Address: 907 LINCOLN ROAD City: STOCKTON Zip: Facility Contact Person: KATHY HALLIGAN Contact Phone No.: 209-4744514 Make/Model of Monitoring System: TLS -350 V/R Date of Testing/Service: 8/16/01 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: 1171 Tank ID: ®In -Tank Gauging Probe: Model: 847390-107 ❑In -Tank Gauging Probe: Model: ®Annular Space or Vault Sensor: Model: 794390420 ❑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 OverfillMgh-level Sensor: Model: 790091-001 ❑Tank Overfill/Mgh-level Sensor: Model: ❑Other, S eci ui a and model in Section E on Page 2 []Other, Specify ui 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 OverfilUlIigh-level Sensor: Model: ❑Tank Overfill/High-level Sensor: Model: ❑Other, Specify ui a and model in Section E on Page 2 ❑Other, Specify ui a and model in Section E on Pa e 2 Dispenser ID: Dispenser ID: ❑In -Tank Gauging Probe: Model: ❑Dispenser Containment Sensor(s): Model: ❑ Shur Valve(s). ❑ Shear Valve(s). []Dispenser Containment Float(s) and Chains ❑Dis enser Containment Float(s) and Chain(s) Dispenser ID: Dispenser ID: ❑In -Tank Gauging Probe: 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. W 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): ❑ System set-up U Alarm history report Technician Name (hint): DON THOWSON Signature: L J, — Certification No.: Testing Company Name: 545923354 License No.: TAIT ENVIRONMENTAL SYSTSEMS Phone No. 588098 (714)560-8222 Page 1 of 3 03/01