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r0 Appendix VI RECEIVED (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.waterboards.ca.gov.) MONITORING SYSTEM CERTIFICATION MAR 3 12014 For Use By All Jurisdictions Within the State of California Authority Cited.Chapter 6.7,Health and Safety Code;Chapter 16,Division 3, Tule 23,California Code ofRegulationENV§ ENTAL This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be I 1�^ monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system owner opera or. °Ylie ffm 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 Telephone Co. dba AT&T California Building No.: UE046 Site Address: 907 LINCOLN RD. City: Stockton Zip: 95207 Facility Contact Person: Dave Dube Contact Phone No.: (209)532-3447 Make/Model of Monitoring System: Veeder Root TLS 350 Plus Date of Testing/Servicing: 3/14/2014 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: UE046UO02 € Tank ID: In-Tank Gauging Probe. Model: 846390-104/716086 In-Tank Gauging Probe. Model: II Annular Space or Vault Sensor. Model: 794390.420/195625 f Annular Space or Vault Sensor. Model: P Piping Sump/Trench Sensor(s). Model: 794380-208/674465 piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: 794380-208/685055 Fill Sump Sensor(s). Model: F Mechanical Line Leak Detector. Model: F Mechanical Line Leak Detector. Model: j FElectronic Line Leak Detector. Model: F Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model:790091 001 Tank Overfill/High-Level Sensor. Model: 1 Other(specify equipment type and model in Section E on Page 2). r Other(specify equipment type and model in Section E on Page 2). Tank IDs Tank ID: In-Tank Gauging Probe. Model: F In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: F Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: F Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: r— Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: F Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: F Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: r— Tank Overfill/High-Level Sensor. Model: Other(specify equipment type and model in Section E on Page 2). F Other(specify equipment type and model in Section E on Page 2). Dispenser ID: Dispenser ID: Dispenser Containment Sensor(s). Model: F Dispenser Containment Sensor(s). Model: Shear Valve(s). r— Shear Valve(s). 1 F Dispenser Containment Float(s)and Chain(s). F Dispenser Containment Float(s)and Chain(s). Dispenser ID: � Dispenser ID: F Dispenser Containment Sensor(s). Model: F Dispenser Containment Sensor(s). Model: Shear Valve(s). r 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 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) : P System set-up Alarm history report Technician Name(print): Dan Luck Signature: X44-oz d044440" Certification No.: B35802 License.No.: 588098 Testing Company Name: TAIT ENVIRONMENTAL SERVICES Phone No.: 714560-8222 Testing Company Address: 2131 SOUTH DUPONT DRIVE ANARE NLCA92806 Date of Testing/Servicing: 3/14/2014