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Appenift VI <br /> (Coples of hionkaft Sydenh Certification form and t13T Mankoft Plat Plan at INjrAwww. ce.gov) <br /> Cefdrication <br /> For Use ByA1 Airbailaffixis Mda tike State of Odbirrife <br /> Art OW CAB&ChWW 8 7. and SWW Caft 14 Dh don$Ift 24 Caftab Cab ofRjpWftm <br /> This form must be used to and sen --d morlNodrg A ar repot meet ba far each <br /> s corldW by ilia lschlidarh who psltonrha the wok copy d tits relaet be <br /> b the tank 711e <br /> coater Isust a copy of this t nn b the batl apsn it feguliftq t 30 d teat dela. <br /> A.GOMM kdbnmdon <br /> FedWr Pacft T Co.dbe AT&T CaKwu CEO PAR&UE020 <br /> Addfew: 4 W.ELM ST. City:LODI IZD:95240 <br /> Fadity Contact Pelson:Conry MkcW Canted Phare No:209.4744022 <br /> Make/Model of Mon :Veeder Root TLS-350 Service Date:05KLIMI1 <br /> B.Inventory of Equ4mient Testo*Cerdftd <br /> Cha ltew spixrolialift bwas to hidlede specille sipidpriveraesu <br /> Tank ID:UE02O0001 Tank ID: <br /> ®In-Tank Ginog Probe Model:8473M107 ❑WTw*GmQhV Probe Model: <br /> ®Annular Spew or Vault Sensor MoM:794390420 OAnnu1wSp3worV&ftSww Modal <br /> ®Piping Sump/Trench Senaor(s) MDde1:784380-Z08 ❑Pilift Sun*/Trench Sensors) Anodal: <br /> ®Fill Sump sensor(e) ModM:794380-208 ❑Ful Sump Sorwr(s) Madel: <br /> Qmachanim Lim Leak Detector Model: p Mechanical Line Leak Detector Model: <br /> n Electronic une Leak Detector Model: ❑Electrork.line leak Detector Model: <br /> ®Tank Overfill I High Level Sensor Madel:780091-001 p Tank Overfill I High Leval smear Madel: <br /> ®Other(Specify equipment type and model In Section E on Page 2) ❑Other(Spar eiiulprrwit type and model In Section E an Pap 2) <br /> Tank ID: Tank ID: <br /> ❑In Tank Geugav Probe Model: p to-Tank Gauging Probe Medd: <br /> ❑Annular Spaos or Vault Swam Model: ❑mrader Space or Vault Sensor AAodM <br /> ❑POV Sump I Trench Seniims) Model: ❑Pith Sump I Trench Sensor(s) Model: <br /> ❑FTfi sump (s) Model: ❑Fit Sump Sensor(s) Model: <br /> ❑Mechanical Line Leak Detector Modet ❑Mechanical Une Lea Detector Model: <br /> U Electronic Line Leak Detector Model: U Electronic Lkwe Leak Detector Model: <br /> p Tank Overt I Nigh Level Sensor Model: ❑Tank Overfill/High Level Sensor Model: <br /> El Oilier(Spec hV sctuipment tyle:and model In Section E an Page 2) ❑Otker(SpecMy type and model In Section E an Page 2} <br /> Dispenser ID: Dispenser ID: <br /> ❑owponsw Coitainment Sensors) Model ❑Oispeniser Containment Sensor(s) Model: <br /> ❑shear Vawe(s) ❑Shm Valves) <br /> n Dispenser Containment Floal(s)and Chain(s) ❑DispenserContainment Fbegs)and C haln(s) <br /> Dispenser ID: Dispenm ID: <br /> ❑Dispenser Cmitainmont Sonsor(s) Model: ❑Dispenser Contakimart swm*s) Model: <br /> ❑Shear Vadve(s) p shear Vaive(s) <br /> ❑Dispenser Containment Fkiags)and Chain(s) p Dispenser Contalmnent RoWs)and Chein(s) <br /> Dismser ID: Disp er ID: <br /> El Dapenser Containment Sermgs) Model: ❑Dispenser Co dart Sensors) MOM: <br /> FI Shear Valves) _ . [J Shear Valve(s) <br /> ❑Dispenser Containment Flat(s)and Chains) ❑Dispernser Contefriment"a)and Chains) <br /> -If the lankly contains more tanks or dispensers,copy this form kclude formation for every tank and at the facaty. <br /> C.Certification-i cenffyy that the eyulDr_+�erlt want(i d in a" was Ins "rvicedi In et mdence with the <br /> man to iters Ce roncetlon is wdbntration(e4e.ma mw )necessary to verihr <br /> that Oft infonnetfon is correct and a Plot Plan shohlti the layote of nsmfitottng For any t caplaole or <br /> gelmrating such reports,i Ih,m also a copy d the napast"(check an that ): <br /> ® !!!�R IN his"refloat <br /> Technician Name nt):Vidor Guerrero Si nature: <br /> Cer ificeMon No:036532 111cense No: <br /> Testing Company Name.TAIT ENVIRONMENTAL SERVICES �. Phone No: 714 560-8222 <br /> T2!MM Company Address:2131 South DupM Drive Anaheim CA 92806 IDO d T SBiV '1 .06102011 <br /> Monitoring System Certification Page 1 of 4 112/07 <br /> a 2�2em7 <br />