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Appendix VI (Copies of Monitoring System C tion form and UST Monitoring Piot Pian avails hftp://www.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, Title 23, California Code of Regulations This foam 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 ownerioperator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Faciii : Pacific Bell Telephone Co. dba AT&T California GEO PAR # UE046 Address: 907 LINCOLN RD. City: STOCKTON Zi : 95207 FaciliN Contact Person: Connie Mitchell Contact Phone No: 209-598-5155 Make/Model of Monitoring System: Veeder Root TLS 350 Service Date: 05/06/2010 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/servlced: Tank ID: UE046UO02 Certification No: B35337 License N 88098 Tank ID: Phone No: 714 560-8222 ® In -Tank Gauging Probe Model:846390-104 ❑ In -Tank Gauging Probe Model: ® Annular Space or Vault Sensor Model:794390-420 ❑ Annular Space or Vault Sensor Model: ® Piping Sump / Trench Sensors) Modet:794380-208 ❑ Piping Sump / Trench Sensors) Model: ® Fill Sump Sensor(s) Model:794380.208 ❑ Fill Sump Sensor(s) Model: ❑ Mechanical Lane Leak Detector Model: ❑ Mechanical Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: ® Tank Overfill l High Level Seng 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) 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 Floats) and Chain(s) Dispenser lD: Dispenser ID: ❑ Dispenser Containment Sensor(s) Model: ❑ Dispenser Containment Sensors) Model: ❑ Shear Valve(s) ❑ Shear Valve(s) ❑ Dispenser Containment Float(s) and Chafn(s) ❑ Dispenser Containment Float(s) and Chain(s) Dispenser ID: '. Dispenser lD: El Dispenser Containment Sensors) {el: ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valve(s) ❑ Shear Valve(s) ❑ Dispenser Containment Float(s) and Chain(s) I ❑ Dispenser Containment Floats) and Chain(s) ` If time 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, l have also attached a copy of the report; (check all that apply): ® System set-up ® Alarm history report Technician Name (Print): John Cascio Signature: Certification No: B35337 License N 88098 Testing Company Name: TAIT ENVIRONMENTAL SERVICES Phone No: 714 560-8222 Testing Company Address: 2131 South Dupont Drive Anaheim CA 92806 Date of Testing/Servicing: 05/06/2010 Monitoring System Certification Page 1 of 4 12107 1 2/21/07