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Appendix Vi (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 BuildingNo.: UG010 Site Address: 1812 COLEY AVE. City: Escalon Zip: 95320 The Facility Contact Person: Connie Mitchell Contact Phone No.: 209-474-4022 Make/Model of Monitoring System: Veeder Root TLS -350 Date of Testing/Servicing: 4/25/2012 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: UG 01OU001 V=......__..... ........... . Tank ID: F In -Tank Gauging Probe. Model: 847390-103 r In -Tank Gauging Probe. Model: P_' Annular Space or Vault Sensor. Model: 794390-420 r Annular Space or Vault Sensor. Model: F' Piping Sump/ Trench Sensor(s). Model: 794380-208 r Piping Sump/ Trench Sensor(s). Model: r Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: € F Mechanical Line Leak Detector. Model: r Mechanical Line Leak Detector. Model: F Electronic Line Leak Detector. Model: r Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: 790091-001 r Tank Overfill/ High -Level Sensor. Model: Other (specify equipment type and model in Section E on Page 2). € r Other (specify equipment type and model in Section E on Page 2). Tank ID: `Tank ID: F In -Tank Gauging Probe. Model: F In -Tank Gauging Probe. Model: i F Annular Space or Vault Sensor. Model: r Annular Space or Vault Sensor. Model: F Piping Sump/ Trench Sensor(s). Model: Piping Sump/ Trench Sensor(s). Model: F Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: r Mechanical Line Leak Detector. Model: r Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: r Electronic Line Leak Detector. Model: r Tank Overfill/ High -Level Sensor. Model: r Tank Overfill / High -Level Sensor. Model: € F Other (specify equipment type and model in Section E on Page 2). r Other (specify equipment type and model in Section E on Page 2). Dispenser ID: Dispenser ID: r Dispenser Containment Sensor(s). Model: r Dispenser Containment Sensor(s). Model: F Shear Valve(s). r Shear Valve(s). F Dispenser Containment Float(s) and Chain(s). i r Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID € F Dispenser Containment Sensor(s). Model: r Dispenser Containment Sensor(s). Model: F Shear Valve(s). r Shear Valve(s). F Dispenser Containment Float(s) and Chain(s). r Dispenser Containment Float(s) and Chain(s). *If the facility contains more tanks or dispensers, copy this form. Include irrtbrmaticn for every tank and dispenser at the tacthty. 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 any equipment capable of generating such reports, I have also attached a copy of the report; (check all that apply) : P System set-up r Alarm history report Technician Name (print): John Cascio Signature: Certification No.: B35337 License. No.: 588098 Testing Company Name: TAIT ENVIRONMENTAL SERVICES Phone No.: 714560-8222 Testing Company Address: 213€ soUTHDUPDNT DRrvE, ANAHEIM, CA928o6 Date of Testing/Seryicing: 4/25/2012