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0 Appendbi: V1 0 (Copies of Monitoring system Certification form and UST Monitoring Plot Phw available at Wjtwww.waterboards.cagov) Monitoring System Ce ion Far (Am By A# J MU*l the SW& of Caftmia AvOo* Ole& Cha pW & 7, Heaffi and SaWy Code. Chapter 15, DW&W 3. Me U CaNbmia CD* of Regufai%= This tam must be used ID document testing and servicing of monitoring equpnent A separate certification or report must be prepared for each nwnbft system control panel by the ladmiden who powme the work. A copy of We loom must be provided 10 ow in* system ownedoperstor. The ownerloperehor must submit 8 copy Of On loom to thelocal agency regulalling UST system wIWn 30 days of test daft. 14. WIROMFOR Bowl%" 1116go,swo 5 FacnitT. Pacific Ben Tel hone Co. dba -AT&T California GEO PAR # UE020 Address: 124 W. ELAM ST. Ck. LODI 42 Facilly contact Person: Connie Mitchel — Contact Phone No: 209-474-4022 Make/Model of Moriftfing System: Veeder Root TLS 350 Service Date: 05/18/2010 B. inventM of Equipment TOSWICwtillOd —A&W—Rulk-wi. if ft ledlity cmftft more tuft or dbpwmM copy vols form. linkide liftwellon for every tank ana Gisperwer a one rdaw. m"*WdW� aeCordefICS, With C. Cerifflimadon- I ceriffy OW the equillmeril: Werdlill9d I" Oft dOw=wd I "wa� In IfIlmdachwers! guldellries. Aftchad th this CarWicallorl is brformadon (( was raw checkileft) necessary the to wedify that this kdonmidw Is correct and a Plot Plan showim the kryad of =ng eqFor any eqtIlpment capable of gerwradrig such reports, I have also ausched a copy of the repott, (check all that 8=)r�: to sysbim set -U0 Alarm history report Tecirinnan Name (Print) John Casclo Ceafficadon No: 835337 License NO*j88M Tes*m Company Name: TArr ENVIRONMENTAL SERVICES Phorate No: (714) 560-8222 I21!!gg Com p@ny Address: 2131 South Du rpt Drive Anaheim, CA 92806 Date of Teshn/SendqLng: 0511812010 Monitodw System Codification page I of 4 12A07 2121/07 Tank ID: U E02DU001�. Tank ID: (9 ki-Tank Gauging Probe MoM:647390.107 ❑ In -Tank Gauging Probe Model: N Annuier space or vault sens" Model:794390420 ❑Armular Specs or Vault San= Model: 19 Piping Sum /Tiencli Setwor(s) MDdel-794360-208 ❑ Piping Sump I Trench SensoKs) Model: 0 FIB Sump Sansor(s) Model:7943110,208 ❑ Fill Sump Sensor(s) Model: [] medwkW Lore Look Detector Modef: 0 Medwkal Urn Leek Detector model: C1 Becironic Une Leak Detector mom: D Electronic Line Look Detector Modet Tank Overfill I HIO Level Sensor MOdOI:790091-001 0 Tank Overfill I High Level Sensor Model: Oom (Specify qquIproent type and model in Section E on Pap 2) 0 Dow (Spa* "Wpmeffl type and model in Section E an Page 2) Tank ID: Tank ID: ❑ WTe* Gauging Probe Model: 0 In -Tank Gouging Probe Mwel: ❑Annular Space or Vault SMW Modet C] Annular Specs or Vault Sensor Model: ❑ PON Sump / Trench Sensor(s) Model: 0 piping Sump / Trench Sensof(s) Model: 0 FIN Sump Sensor(s) Model: 0 Fin Sump Sensor(s) Model: ❑ Mgd=kW Urn Look Detector Model: 0 medw*W Lim Leak Detector Model: ❑Bectrordo Line Leak Detector Model- ❑ Electronic Lim Leek Detector Model: ❑ Tank OveM I HM! Level Ser%&Of Model: ❑ Tank OweAl I fth Level Saw Model: ❑ olloar (spectly equipment type and model in Socilon E on Page 2) [3 ollier (Specify eopment type and model too Section E on Page 2)_ Disoenser ID: Q!§penser ID: [I Dispenser CO*Wnwt SOMOOF(s) Model: [I Dispenser OxilainmOnt SW900) Model: 0 Show V* -*B) 0 Sitear VaWs) [I Dispenser CwftWrwkt Flings) and Owln(s) 0 Dispensw containment Fioags) and Chains) DkVwser 1Q, Dispenser 1Q* [] Dispenser Contownwit Sw*Of(s) MOM: 0 Dispenser Caftinment Swwr(s) Model: OShmVafve($) 0 Shear Valve(s) [I DWponw Conlairmwit "s) and Chain(s) C] FlosKs) and Own(s) P!Muser 1D. Disomser ID: El Disperser CatownOld SOV19043) Model: 0 DkWw CWntalmnent Sensor(S) Model: 0 Show VaWs) 0 Shear valve(s) [] DW=w Containawit FkwKs) and Chains) E] Dbpmw CiontskirroOnt "a) and Chess) if ft ledlity cmftft more tuft or dbpwmM copy vols form. linkide liftwellon for every tank ana Gisperwer a one rdaw. m"*WdW� aeCordefICS, With C. Cerifflimadon- I ceriffy OW the equillmeril: Werdlill9d I" Oft dOw=wd I "wa� In IfIlmdachwers! guldellries. Aftchad th this CarWicallorl is brformadon (( was raw checkileft) necessary the to wedify that this kdonmidw Is correct and a Plot Plan showim the kryad of =ng eqFor any eqtIlpment capable of gerwradrig such reports, I have also ausched a copy of the repott, (check all that 8=)r�: to sysbim set -U0 Alarm history report Tecirinnan Name (Print) John Casclo Ceafficadon No: 835337 License NO*j88M Tes*m Company Name: TArr ENVIRONMENTAL SERVICES Phorate No: (714) 560-8222 I21!!gg Com p@ny Address: 2131 South Du rpt Drive Anaheim, CA 92806 Date of Teshn/SendqLng: 0511812010 Monitodw System Codification page I of 4 12A07 2121/07