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ONI NG SYSTEM CE TIF CATION 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: ESCLCAt I Site Address: 1812 COLEY AVENUE City: ESCALON Zip: Facility Contact Person: KATHY HALLIGAN Contact Phone No.: 209-474-4514 Make/Model of Monitoring System: VEEDER-ROOT TLS-350 Date of Testing/Service: 8/11/03 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: 794 Tank ID: ZIn-Tank Gauging Probe: Model: 847390-101 ❑h1-Tank Gauging Probe: Model: ZAnnular Space or Vault Sensor: Model: 794390-420 ❑Annular Space or Vault Sensor Model: ZPiping 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: ZTank Overfill/High-level Sensor: Model: 790091-001 ❑Tank Overfill/High-level Sensor: Model: ❑Other, Specify equip- a and model in Section E on Page 2 ❑Other,Specify a ui a 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 e ui a and model in Section E on Page 2 ❑Other, Specify equip.type and model in Section E on Page 2 Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensor(s): Model: ❑Dispenser Containment Sensor(s): Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Float(s)and Chain(s) ❑Dis enser 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 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): Z System set-up Z Alarm histor rep t Technician Name(Print): FRED RIDDLES Signature: Ik V1 Certification No.: 9579 License No.: 588098 Testing Company Name: TAIT ENVIRONMENTAL SYSTEMS Phone No.: (714)560-8222