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R 16., 0 Appendix VI ut, (Copies of Monitoring System Certification form and USTMonitoring Plot Plan available at ca. gov .) MONITORING SYSTEM CERTIFICATION MAR 0 3 2016 For Use By All Jurisdictions Within the State of California Authority Cited. Chapter 6.7, Health andSafety Cade; Chapter l6, Division 3, Tule 23, California Code ofRegulatio ; RO MENTAL This foam must be used to document testing and servicing of monitoring equipment. A separate certification or report must monitoring system control panel by the technician who perforans the work. A copy of this form must be provided to the tank sy, fern owner/operator. The owner/operator must submit a copy o fthis form to the local agency regulating US"f systems within 30 days of test date. A. General Information Facility Name: Pacific Bell Telephone Co dba ATT California Facility ID: UG010 Site Address: 1812 Coley Ave. Facility Contact Person: Thuy Tran City Escalon lip: 95320 Contact Phone No.: 209-474-4022 Make/Model of Monitoring System: Veeder Root TLS -350 Plus Date of Testing/Servicing: 02-18-2016 H. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: r TanklD: UG0100001 :Tank ID: � �� I11 ❑X In -Tank Gauging Probe. Model: 847390 107 / 731089 =❑ In -Tank Gauging Probe. Model: � Annular Space or Vault Sensor. ( Model: 794390-420 / 490104 '❑ Annular Space or Vault Sensor. Model E? I X Piping Sump / Trench Sensor(s). Model: 794380-208 / 515978 li i ❑ Piping Sump / Trench Sensor(s). iE Model: I❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model ,_❑ Mechanical Line Leak Detector. i= Model: ij❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Ful 1^1 Tank Overfill / High -Level Sensor. Model: 790091-001 = ❑ Tank Overfill / High -Level Sensor. Model „( ❑x Other (s ecequipment tYpe and model in SectionE on Page 2). ❑Other (specify equipment te and model i= in Section on Page 2). J 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: i❑ Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: i _❑ Fill Sump Sensor(s). Model: �❑ Fill Sump Sensor(s). Model: #❑ Mechanical Line Leak Detector. Model: t �❑ Mechanical Line Leak Detector. Model: �❑ Electronic Lice Leak Detector. Model: i 1❑ Electronic Line LeakDetedor. Model: ❑ Tank Overfill / High -Level Sensor. Model: :❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in SectionE on Page 2). ___.. ❑ Other (specify equipment tvpe and model in Section E on Page 2) ID: Dispenser ID )_ lDispenser = ❑ Dispenser Containment Sensor(s). Model: '❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). JEIS hear Valve(s). E]Dispenser Containment Float(s) and Chain(s). ❑Dispenser ContannmentFloat(s)atnd Chain(s). Dispenser ID: DispenserID.�?F❑Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). lr[F-lS Model: Shear Valve(s).hear Valve(s). i q ❑ 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 correctand a Plot Plan showing the layout of monitoring equipment. For a ny equipment capable of generating such reports, I have also attached a copy of the report; (check all that apply) : ❑i� System set-up ❑x Alarm history report Technician Name (print): John Caseio Signature Certification No.: B35337 License. No.: 588098 Testing Company Name: TAIT ENVIRONMENTAL SERVICES Phone No.: 714560-8222 Testing Company Address: 2131 soUTHDUPONTDRIVE, ANAHEIKCA92806 Date of Testing/Servicing 02-18-2016