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Appendix V1 (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at gov .) MONITORING SYSTEM CERTIFICATION For Use By All.1urisdictions 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. Acopy of this form must be provided to the tank system owner/operator. The owner/operator must submit a copy ofthis 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: Gary Chi mienti Contact Phone No.: (925)468-8103 Make/Model of Monitoring System: Veeder-Root TLS-350 plus Date of Testing/Servicing: 4/5/2013 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: TankID: UE020U001 Tank ID: UE020A003 R' In-Tank Gauging Probe. Model: 847390-107/439514 j In-Tank Gauging Probe. Model: R_ Annular Space or Vault Sensor. Model:794390-420/441672 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: F Fill Sump Sensor(s). Model: 794380-208/675586 Fill Sump Sensor(s). Model: F Mechanical Line Leak Detector. Model: F Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: 790091-001 H Tank Overfill/High-Level Sensor. Model: R_ Other(specify equipment type and model in Section E on Page 2). Other(specify equipment type and model in Section E on Page 2). ...... ftmwwmwmm i Tank ID: Tank ID: In-Tank Gauging Probe. Model: F In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: Annular Sp e 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: f Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: r Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: F Tank Overfill/High-Level Sensor. Model: Tank Overfill/High Level Sensor, Model: Other(specify equipment type and model in Section E on Page 2). 2).. Other(specify equipment type and model in Section E on Page Dispenser ID: Dispenser ID: r Dispenser Containment Sensor(s). Model: i�F Dispenser Containment Sensoqs). Model: F Shear Valve(s). F Shear Valve(s). f Dispenser Containment Float(s)and Chain(s). r Dispenser Containment Float(s)and Chain(s). ........... i! Dispenser ID: Dispenser ID: Dispenser Containment Sensor(s). Model: Dispenser Containment Sen so i(s). Model: F Shear Valve(s). S hea r Va IN,e(s). F Dispenser Containment Float(s)and Ch ain(s). I r 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) System set-up 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: 2131 SOUTTIDUPOW DRIVE,ANAHEIM,CA92806 Date of Testing/Servicing: 4/5/2013