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A 0 wppenuix vil (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.waterboards.ca,gov) Monitoring System Certification For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code, Chapter 16, Division 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 form must be provided to the tank system owner/operator. The 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: Pacific Bell Telephone Co. dba AT&T California GEO PAR # UE020 Address: 124 W. ELM ST. Cit : LODI Zi :95242 Facility Contact Person: Connie Mitchell Contact Phone No: 209-598-5155 Make/Model of Monitoring System: Veeder Root TLS 350 Service Date: 07/08/2010 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicate specific equipment InsaBCted/servlced: Tank ID: UE0200001 Tank ID: ❑ In -Tank Gauging Probe Model: ❑ In -Tank Gauging Probe Madel: ❑ Annular Space or Vault Sensor Model: ❑ Annular Space 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: ❑ Mechanical Line Leak Detector Model: ❑ Mechanical Une Leak Detector Model: ❑ Electronic Line Leak Detector Model: D Electronic Line Leak Detector _MO_ odel; ❑ Tank Overfill / High Level Sensor Model: ❑ Tank Overfill / High Levet Sensor Model: ® Other (Specify equipment type and model in Section E on Page 2) ❑ Other (Specify equipment type and model in Section E on Page 2) Tank ID: Tank lD: ❑ In -Tank Gauging Probe Model: ❑ In -Tank Gauging Probe Model: ❑ Annular Space or Vault Sensor _Model: ❑ Annular Space or Vault Sensor Model: ❑ Piping Sump / Trench Sensor(s) Model: ❑ Piping Sump / Trench Sensor(s) Model: El Fill Sump Sensor(s) Model: ❑ Fill Sump Sensor(s) Model: ❑ 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 Overfill / High Level Sensor Model: ❑ Other (Specify equipment type and model in Section E on Page 2) ❑ Other (Specify equipment type and model in Section E on Page 2) Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensors) Model: ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valve(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: ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valve(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: ❑ Dispenser Containment Sensor(s) Model: Q Shear Valve(s) ❑ Shear Valve(s) ❑ Dispenser Containment Float(s) and Chain(s) ❑ Dispenser Containment Float(s) and Chain(s) 'It 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): {y ® Svsfam Alarm. hias --^.+ Technician Name (Print): Victor Guerrero Signature: Certification No: 836532 License No: 88098 Testing Company Name: TAIT ENVIRONMENTAL SERVICES Phone No: 714 560-8222 ITesting Company Address: 2131 South Dupont Drive Anaheim CA 92806 Date of Testing/Servicing: 07/08/2010 ivionnonng oystern Certification Page 1 of 4 12/07 1 901/07