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Appendix VI (Copies of Monitoring System Certification fort and LIST Monitoring Plot Pian available at http:/twww.waterboards.ca.gov) 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, True 23,Califomis Code of Regulations This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be each monitoring system control panel by the technician who performs the work.A copy of this farm must be ftto the tanks owner/ operator.must submit a copy of this farm to the local agency regulating UST systems within 30 days date. m 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 Mitchell Contact Phone No:209-474-4022 Make/Model of Monitoiin System:Veeder-Root TLS-350 Service Date:04/21/2011 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicans specNtc equipment Inspect"serviced: Tank ID: UE046UO02 Tank ID: ®In-Tank Gauging Probe Model:8463W104 ❑In-Tarlo Gauging Probe Model: ®Annular Space or Vault Sensor Mode1:794390.420 ❑Annular Space or Vault Sensor Model: ®Piping Sum/Trench Sensor(s) Model:794360-208 ❑Piping Sump/Trench Sensor(s) Moder: ®Fitt Sump Serr"(s) Model:794380-206 ❑Fin Sump Sensor(s) Model: ❑Mechanical Line Leak Detector Model: ❑Mechanical Line Leak Detector Model: ❑Electronic Line Leak Detector Madel: ❑Electronic Una Leak Detector Model: ®Tank Overfill/High Level Sensor Model:Other ❑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) TanklD: TanklD: ❑In-Tank Gauging Probe Model: ❑In-Tank Gauging Probe Model: ❑Annum Space or Vault Sensor Model: ❑Annular Space or Vault Sense f_1 Piping Sump/Trench Sen Model: its) Moder: ❑Piping Sump/Trench Sensor(s) Model: ❑Fill Sump Sensor(s) Model: ❑Fill Sump Sensor(s) Model: ®Medwdcal Line Leak Detector Madel: ❑Mechanical Line Leak Detector Model: ❑Electronic Line Leak Detector Model: ❑Electronic Line Leak Detector Model: ❑Tank Overfill/High Levet Sensor Model: ❑Tank Overfill/High Level Sensor Madel: ❑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: DispenserlD: ❑Dispenser Containment Sensor(s) Model: ❑Dispenser Containment Sensor(s) Madel: ❑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) Modet: ❑Shear Valve(s) ❑Shear Valve(s) ❑Dispenser Containment Float(s)and Chain(s) ❑Dispenser Containment Floats)and Chaln(s) DispenserID: 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 Identified in this document was inspectediserviced 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): ®S st t-u arm history report Technician Name (Print):Wesley Morrison Si natur Certification No: B38044 License No: 5880 Testrig Company Name:TAIT ENVIRONMENTAL SERVICES Phone No: 714 560-8222 Testis Company Address:2131 South Dupont Drive Anaheim CA 92806 jDate of Testis /Servicin :04/21/2011 Monitoring System Certification Page 1 of 4 12/07 1 2/21/07