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PU onitorin System Ce 'ficatiose By All Jurisdictions Within the State of California Authority Cited.Chapter 6.7, Health and Safety Code,Chapter 96,Division 3, Title 23, Califomis Code of Regulations This form must be used to document testing and servicing of monitoring equipment.A separate certificationor report must be prepared for each monitoring system control panel by the technician who performs the work.A copy of erns o u e prove a iii fanK System owner/operator.The owner opera or Must SUDMit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility: Pacific Bell Telephone Co. dba AT&T Califomia GEO PAR#UE046 Address: 907 LINCOLN RD. City: STOCKTON Zi : 95207 Facility Contact Person: Connie Michell Contact Phone No: Make/Model of Monitoring System:Veeder Root TLS 350 Service Date: 05/02/2 B. Inventory of Equipment Tested/Certified 1 9 200 Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: UE0460002 Tank ID: ' ` UN CV" `- AVEPERM!T ®In-Tank Gauging Probe Model:847390-104 ❑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:350 series B1 ❑Tank Overfill/High Level Sensor Model: ❑Other(Specify equipment type and model in Section E on Page 2) ❑Other(Specify equipment type 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 equipment type and model in Section E on Page 2) ❑Other(Specify equipment type and model in Section E on Page 2) Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensor(s) Model: ❑Dispenser Containment Sensors) Model: ❑Shear Valve(s) ❑Shear Valve(s) ❑Dispenser Containment Float(s)and Chain(s) ❑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) ❑Dispenser Containment Float(s)and Chain(s) ❑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) ❑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. Certification-I certify that the equipment WentWWd in this document was inspectediserviced in accordance the manufacturers'guidelines.Attached to this Certification is inform (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 ®Alarm history report Technician Name(Print):John Cascio Si nature: Certification No: 835337 License 588098 Testing Company Name: TAIT ENVIRONMENTAL Phone No: (714)560-8222 SERVICES Pagel of 4