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0 Appendix VI 10 (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.waterboREPEIVED a. .) MONITORING SYSTEM CERTIFICATION APR 09 '1014 For Use By All Jurisdictions Within the State of California Authority Cited:Chapter 6.7,Health and Safety Code,Chapter 16,Division 3, Tule 23,California Code ofRegulati ��® This form must be used to document testing and servicing of monitoring equipment.A separate certification or report mus 1 t monitoring system control panel by the technician who performs the work.A copy of this form must be provided to the tank e 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.: UE020 Site Address: 124 W. ELM ST. City: Lodi Zip: 95240 Facility Contact Person: Dave Dube Contact Phone No.: 209-474-4022 Make/Model of Monitoring System: Veeder Root TLS-350 plus Date of Testing/Servicing: 3/27/2014 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: UE020U001 Tank ID: UE020A003 In-Tank Gauging Probe. Model: 847390-107/439514 F In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 794390420/441672 r Annular Space or Vault Sensor. Model:794380-344/844409 Piping Sump/Trench Sensor(s). Model: 794380-208/685112 F Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: 794380-208/657586 Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: F Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: 790091-001 Tank Overfill/High-Level Sensor. Model: 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: In-Tank Gauging Probe. Model: F hi-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: r Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: tl Piping Sump/Trench Sensor(s). Model: F Fill Sump Sensor(s). Model: F Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: F Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: F Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: F Tank Overfill/High-Level Sensor. Model: 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). .Dispenser ID: Dispenser ID: Dispenser Containment Sensor(s). Model: r Dispenser Containment Sensor(s). Model: Shear Valve(s). r Shear Valve(s). Dispenser Containment Float(s)and Chain(s). F Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: F Dispenser Containment Sensor(s). Model IF Dispenser Containment Sensor(s). Model: F Shear Valve(s). F Shear Valve(s). Dispenser Containment Float(s)and Chain(s). F 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 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) : F System set-up F Alarm history report Technician Name(print): Victor Guerrero r Signature: Certification No.: B36532 License.No.: 588098 Testing Company Name: TAIT ENVIRONMENTAL SERVICES Phone No.: 714560-8222 Testing Company Address: 2131 SOUTH DUPONT DRIVE.arrrirmKCA92806 Date of Testing/Seryicing: 3/27/2014