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Appendix VI f (Copies of Monitoring System Ceow. form and UST Monitoring Plot Plan evailabl ttp:/lwww.waterboards.ca.gov) Monitoring System Certification For Use By A# Jurisdictions Within the State of Callfiomia Authority Cited. Chapter 8. 7, Health and Safety Code; Chapter 15, Division 3, Title 23, Califomia 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 parlors the work. A copy of this form must be provided to the tank system ownerloperator. The ownerloperstor must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A_ Genaral Information Facility: Pacific Bell Tele hone Co. dba AT&T Califomia GEO PAR # UE020 Address: 124 W. ELM ST. City: LODI Zi .. 95242 !Facili Contact Person: Connie Mitchell Contact Phone No: 209-474-4022 Make/Model of Monitoring System: Veeder Root TLS 350 Service Date: 05/18/2010 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment ins serviced: 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 equipmerd Identified in this document was ins edlserviced In accordance with the manufacturers' guidelines. A to is Certification is information (e.g. mantti Wirers' checklists) necessary to verify that the Information is correct and a Piot Plan shout 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): 9 System set-up ® Alarm history report Technician Name (Print): John CascioSi nature: Certification No: 835337 I License No -588098 Tank ID: UE0200001 Testing Company Address: 2131 South Dupont Drive Anaheim CA 92806 1 Date of Testing/Servicing: 05/18/2010 Tank ID: 19 In -Tank Gauging Probe Model:847390-107 ❑ In -Tank Gauging Probe Model: ® Annular Space or Vault Sensor Model:794390-420 ❑ Annular Space or Vault Sensor Model: ® Piping Sump/ Trench Sensor(s) Model:794380-208 ❑ Piping Sump / Trench Sensor(s) Model: ® Fill Sump Senso(s) Model:794380-208 ❑ Fill Sump Sensors) Model: ❑ Mechanical Line Leak Detector Model: ❑ Mechanical Line Leak Detector Model: ❑ Electronic tine Leak Detector Model: ❑ 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 to Section E on Page 2) ❑ Other (Specify equipment type and model in Section E on Page 2) Tank ID: Tank ID: ❑ krTank Gauging Probe MOdel: ❑ In -Tank Gauging Probe Model: ❑ Annular Space or Vault Sensor Model: ❑ Annular Space or Vault Sensor Model: ❑ Piping Sump 1 Trench Sensor(s) Model: ❑ Piping Sump l Trench Sensor(s) Model: ❑ Fill Sump Sensor(s) Model: ❑ Fill Sump Sensor(s) Model: ❑ Mechanical Line Leak Detector Model: ❑ Mechanical Line Leak Detector Model: ❑ Electronic Line Leak Detector Modem ❑ Electronic Line Leak Detector Model: ❑ Tank Overfill / High Level Sensor Model: ❑ Tank Overfill l 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. lD' ❑ Dispenser Containment Sensor(s) Model: ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valve(s) ❑ Shear Valve(s) ❑ Dispenser Containment Float(s) and Chains) ❑ Dispenser Containment Floats) 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 Floats) 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) 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 equipmerd Identified in this document was ins edlserviced In accordance with the manufacturers' guidelines. A to is Certification is information (e.g. mantti Wirers' checklists) necessary to verify that the Information is correct and a Piot Plan shout 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): 9 System set-up ® Alarm history report Technician Name (Print): John CascioSi nature: Certification No: 835337 I License No -588098 Testing Company Name: TAIT ENVIRONMENTAL SERVICES I Phone No: 714 580-8222 Testing Company Address: 2131 South Dupont Drive Anaheim CA 92806 1 Date of Testing/Servicing: 05/18/2010 Monitoring System Certification Page 1 of 4 12/07 1 2/21107