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Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http:l/www.waterboards.ca.gov) Monitoring System Certification For Use By Ali Jurisdictions I fthin the State of Califomis Authority Cited:Chapter 6.7, Health and Safety Code;Chapter 18. Division 3, Title 23, Califomia 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 form must be provided to the tank system owner/operator.The ownerloperator must submit a copy of this form to the local agency regulating LIST systems within 30 days of test date. A. General Information Facility: Pacific Bell Telephone Co.dba AT&T California GEO PAR#UE042 Address: 345 N. SAN JOAQUIN City: STOCKTON Zip: 95202 Facil' Contact Person: Connie Mitchell Contact Phone No: 209-598-5155 Make/Model of Monitoring System.Veeder Root TLS 350 Service Date:05113/2010 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspectediservk:ed: Tank ID: UE042UO01 Tank ID: ®In-Tank Gauging Probe Model:847390-109 ❑in-Tank Gauging Probe Madel: ®Annular Space or Vault Sensor Model:794390.420 ❑Annular Space or Vault Sensor Model: ®Piping Sump 1 Trench Sensor(s) Model:794380-208 ❑Piping Sump i Trench Serwor(s) Model: ®Fill Sump Sensor(s) Model:794380-208 ❑Fill Sump Sensor(s) Madel: ❑Mechanical Line Leak Detector Model: ❑Mechanical Line Leak Detector Model: ❑Electronic Line Leak Detector Model: ❑Electronic Line Leak Detector Model: ®Tank Overfill i High Level Sensor Model:Other ❑Tank Overfill i High Level Sensor Model: ®Other(Specify equipment type and model in Sedan E on Page 2) ❑Other(Specify equipment type and model in Section E on Page 2) Tank ID: Tank 10: ❑In-Tank Gauging Probe Model: ❑in-Tank Gauging Probe Model: ❑Annular Space or Vault Sensor Model: ❑Annular Space or Vault Sensor Model: ❑Piping Sump I Trench Sensor($) Model; ❑Piping Sump/Trench Sensor(s) Model: ❑Fill Sump Sensor(s) Mme: ❑Fill Sump Sensor(s) Model: ❑Mechanical Line Leak Detector Model: ❑Mechanical Line Leak Detector Mom: ❑Electronic Line Leak Detector Model: ❑Electronic Line Leak Detector Model: ❑Tank Overfill/High Level Sensor Model: ❑Tank Overfill I High Level Sensor Model: ❑Other(Specify equipment type and model in Section E on Page 2) ❑Other(Specify equipment type and model In Section Eon Page 2) Dispenser ID: _Dispenser ID: ❑Dispenser Containment Sensor(s) Model: ❑Dispenser Containment Sensors) Model. ❑Shear Vatve(s) ❑Shear Valve(s) ❑Dispenser Containment Float(s)and Chain(s) ❑Dispenser Containment Float(s)and Chain(s) Dispenser ID: _ _ Dispenser ID: ❑Dispenser Containment Sensor(s) Model: T ❑Dispenser Containment Sensor(s) Model: ❑Shear Valve(s) _ ❑Shear Valve(s) ❑Dispenser Containment Float($)and Chain(s) ❑Dispenser Containment Float(s)and Chain(s) DiMnser Ila: Dispenser ID: ❑Dispenser Containment Sensor(s) Model. ❑Dispenser Containment Sensor(s) Model: ❑Shear Vatve(s) _ ❑Shear Valve(s) ❑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 Certiticatlan 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): ®SysWin set-up, 0 AMMU history report Technician Name Print :Victor Guerrero Si nature: Certification No:8365632 License No: 588098 Testing Company Name:TAIT ENVIRONMENTAL SERVICESPhone No: 714 560-8222 TestingCam n Address: 2131 South Dupont Drive Anaheim CA 928011 —. Date of Testing/Servicing: 05/13/2010 Monitoring System Certification Page t of 4 12/07 1 1"l rm