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MONFORING SYSTEM CETI I 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# UG-010 CLLC Code: ESCLCAI l Site Address: 1812 COLEY AVENUE City: ESCALON Zip: Facility Contact Person: BRIAN BOOKMAN Contact Phone No.: 209-541-1125 Make/Model of Monitoring System: VEEDER-ROOT TLS-350 Date of Testing/Service: 8/16/02 B. Inventory of Equipment Tested/Certified Check the appronate boxes to indicatespecific equipment ins ected/serviced: Tank ID: 794 Tank ID: ®In-Tank Gauging Probe: Model: 847390-101 ❑In-Tank Gauging Probe: Model: ®Annular Space or Vault Sensor: Madel: 794390-420 ❑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: ❑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 OverfilUHigh-level Sensor: Model: 790091-001 ❑Tank Overfill/High-level Sensor: Madel: ❑Other, SpSSn auip. and model in Section E on Pa e 2 ❑Other, S ui .pM and model in Section E on Page 2 Tank ID: Tank ID: Oln-Tank Gauging Probe: Model: OIn-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 OverfillMgh-level Sensor: Model: ❑Tank OverfillAligh-level Sensor: Model: ❑Other, Specft Squi . and model in Section E on Page 2 ❑Other, SpLzft ani . and model in Section E on Pa e 2 Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensor: Model: ❑Dispenser Containment Sensor(s): Model: _ ❑ Shear Valve(s). ❑ Shear Valve(s). ODispenser Containment Float(s)and Chain(s) ElDiTenser 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) Dispenser ID: Dispenser ID. []In-Tank Gauging Probe: Model: ❑Dispenser Containment Sensor(s): Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Di user Containment Float(s)and Chain(s) ❑Di user 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 alt that apply): ® System set-up Alarn historeport Technician Name(Print): BRANDON HAM Signature: Certification No.: 3435 License No.: 588098 Testing Company Name: TAIT ENVIRONMENTAL SYSTEMS Phone No.: (714)560-8222 Page 1 of 3 03/01