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Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http : //Nvwnv. waterboards. ca . gov .) MONITORING SYSTEM CERTIFICATION For Use By .411 Jurisdictions Prithin the State of California Authority Cited: Chapter 6. 7, Health and Srfetp 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 perforans the work. A copy of this form must be provided to the tank system owner/operator . The oxvner/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 ATT California Facility ID : UG010 Site Address: 1812 Coley Ave . City : Escalon Zip : 95320 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 : 01 -30-2018 Be Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected /serviced : Tank ID : UG010U001 Tank ID: ❑ In- Tank Gauging Probe . Model : 847390- 107 / 731089 ❑ In -Tank Gauging Probe . Model : 0 Annular Space or Vault Sensor . Model : 794390-420 / 490104 ❑ Annular Space or Vault Sensor . Model : ❑ Piping Sump / Trench Sensor(s). Model : 794380-208 / 515978 ❑ 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 : 790091 -001 ❑ Tank Overfill / High- Level Sensor . Model : ❑X Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID : Tank ID: ❑ hr- 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 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 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 ContaiunentFloat( 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 ContaimmentFloat( s) 01 ^ * If tlr facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facilit eN Co Certification - I certify that the equipment identified in this document was inspected /serviced in accordance with lPimp urers ' guidelines. Attached to this Certification is information ( e. g. manufacturers' checklists ) necessary to verify that thio,�', correctand a Plot Plan showing the layout of monitoring equipment. For a ny equipment capable of generatic uch reportsI�nave a `a whedf copy of the repon4 ; (check all that appl3) Q System set -up Q Alarm history report �/� W� , Technician Name ( print): John Caseio Signature : eaaua ®�O ` 'r get FV /8elto Certification No B35337 License. No . : 588098 140 Testing Company Name : TAIT Envirom rental Services, Inc. Phone No. : 714560- 8222 "! *4 Testing Company Address : 701 N Parkcenter Dr. , Santa Ana, CA, 92705 Date of Testing/Servicing : 01 -30-2018 r/y