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1 MONIT(VING SYSTEM CERTIFIC.TION For Use By All Jurisdictions Within the State of California Authority Cited:Chapter 6.7, Health and Safety Code; Chapter 16, Aivision 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 fform provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency Su UST g systems within 30 days of test date. A. General InformationCLLC Code: SKTNCA16 Facility Name: PACIFIC BELL GEO PAR# UE-R47 Site Address: 4051 NEWTON ROAD City: STOCKTON Zip: Facility Contact Person: LORI WAGNER Contact Phone No.: 209-569-9846 Make/Model of Monitoring System: V/R'I'LS-350 Date of Testing/Service: 8/10/01 B. Inventory of Equipment Tested/Certified Check thea ro riate boxes to indicates ecific a ui ment ius Tatem sed: Tank ID: 2029 Model: ®]n-Tank Gauging Probe: Model: 847390-107 [311n)-Tank Gauging Probe: ®Annular Space or Vault Sensor: Model: 794390420 ❑Ap gar Space or Vault Sensor ModModel:®Piping Sump/Trench Sensor(s): Model: 794390-205 . ❑Pi in Sump/Trench Sensor(s): Model: ®Fill Sump Sensor(s): Model: 794390-205 ❑Fill Sump Sensor(s): ❑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 Overfillffgh-level Sensor: Model: ❑Other,S eci ui a and model in Section E on Pa e 2 ❑nthID Specify ui a and model in Section E on Page 2 Tank ID: ❑ln-Tank Gauging Probe: Model: ❑In-Tank Gauging Probe: Model: ❑Annular Space or Vault Sensor: Model: ❑Annular Space or Vault Sensor Model: pPiping Sump/Trench Sensor(s): Model: ❑Piping p Sensor(s) Sensor(s): Model: ❑Fill Sump Sensor(s): Model: ❑Fill Sump Sensor(s): Mode]: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector Model: pElectronic Line Leak Detector Model: ❑Tank Overfillffgh-level Sensor: Model: ❑Tank Overfill/High-level Sensor: Model: ❑Other,S7Containment i a and model in Section E on P e 2 ❑Other,S i ui . and mode]in Sectqftaagg Dispenser1-2 Dispenser ID: ®DispensModel: 794390- ❑Dispenser Containment Sensor(s): Model: 420 ❑ Shear Shear Valve(s). ❑Dis eraFloats and Chains ❑Dis enser Containment Floats and Chain(s) Dispenser ID: Dispenser ID: ❑In-Tank Gauging Probe: Model: ❑Dispenser Containment Sensor(s): M e ❑Shear Valve(s). El Shear Valve(s). pDis eraser Containment Floats and Chain(s ❑Di enser Containment Floats 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): ❑ System set-up ❑Al_ arm history report BRANDON HAM Signature: . 4Qh OA^ iwar I�11o/t11 Technician Name(Print): License No.: 588098 Certification No.: 393435 Testing Company Name: TAIT ENVIRONMENTAL SYSTSEMS Phone No.: (714)560-8222 Page 1 of 3 03/01 I