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Appendix VI 10 (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://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 ofRegulations 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 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 Telephone Co. dba AT&T California Building No.: UG010 Site Address: 1812 COLEY AVE. City: Escalon Zip: 95320 The Facility Contact Person: Thuy Tran Contact Phone No.: (209) 474-4022 Make/Model of Monitoring System: Veeder Root TLS 350 Plus Date of Testing/Servicing: 3/11/2015 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: ._._. _..,.,.... �• _,...... -3 TankID UG010 U001 Tank ID In -Tank Gauging Probe. Model: 847390-107/731089 In -Tank Gauging Probe. Model: r Annular Space or Vault Sensor. Model: 794390-420/490104 F Annular Space or Vault Sensor. Model: I€ Piping Sump/ Trench Sensor(s). Model: 794380-208/515978 F Piping Sump/ Trench Sensor(s). Model: Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: r Mechanical Line Leak Detector. Model: F Electronic Line Leak Detector. Model: i r Electronic Line Leak Detector. Model: r 79009 1-00 1 � Tank Overfill /High -Level Sensor. Model: F Tank Overfill/ High -Level Sensor. Model: f 1_� Other (specify equipment type and model in Section E on Page 2) F Other (specify equipment type and model in Section E on Page 2). Tank ID ( Tank ID: j F� In -Tank Gauging Probe. Model: ( In -Tank Gauging Probe. Model: F Annular Space or Vault Sensor. Model: F 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: F Mechanical Line Leak Detector. Model: i F Electronic Line Leak Detector. Model: i F 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 IDat r- Dispenser Containment Sensor(s). Model: F Dispenser Containment Sensor(s). Model: F Shear Valve(s). Shear Valve(s). F Dispenser Containment Float(s) and Chain(s) F Dispenser Containment Float(s) and Chain(s) _ .___ _— . --- ... ___ _ _ . _, _...... Dispenser ID: j Dispenser ID: pp� r Dispenser Containment Sensor(s). Model: ii r Dispenser Containment Sensor(s). Model: Ir f Shear Valve(s) Shear Valve(s). IF Dispenser Containment Float(s) and Chain(s) 11 F Dispenser Containment Float(s) and Chain(s) `if the fatuity cor>tains more tames or dispensers, copy tins Corm. include intimation for every tank and dispenser at the tacility. 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) : r System set-up r Alarm history report Technician Name (print): Dan Luck Signature: AA.Az� - EGEI �._ Certification No.: B35802 License. No.: 588098 -) Testing Company Name: TAIT ENVIRONMENTAL SERVICES Phone No.: 714560-8222 AR 2 6 2015 Testing Company Address: 2131 SOUTH DUPONT allVF. ANAHBN1. CA 92 806 Date of Testing/Seryicing: 3/11/2015