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r MONITING SYSTEM CERTIFATION 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 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: TLS-350 V/R Date of Testing/Service: 8/16/01 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates eci c a ue ment ins cted/serviced: Tank ID: 794 Tank ID: ®In-Tank Gauging Probe: Model: 847390-101 ❑In-Tank Gauging Probe: Model: ®Annular Space or Vault Sensor: Model: 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 Overfill/High-level Sensor: Model: ❑Tank Overfill/14igh-level Sensor: Model: ❑Other,Specify ui a and model in Section E on Pa e 2 ❑Other,S eci _Li . e and model in Section E on Pa e 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 ui a and model in Section E on Page 2 ❑Other,Specify ui . e and model in Section E on Page 2 Dispenser ID: Dispenser ID: ❑ln-Tank Gauging Probe: Model: ❑Dispenser Containment Sensor(s): Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dig enser Containment Float(s)and Chain(s) ❑Dis enser 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). ❑Dis enser Containment Floats and Chain(s) ❑Dis enser Containment Float(9 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): O System set-up ❑Arm history report Technician Name(Print): DON THOMPSON Signature: Certification No.: 545923354 License No.: 588098 Testing Company Name: TAIT ENVIRONMENTAL SYSTSEMS Phone No.: (714)560-8222 Page 1 of 3 03/01