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Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at hup://www.waterboatds.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, Diusion 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. A copy of this form must be provided to the tank system owner/operator own er/operator must submit a copy o f this form to the local agency regulating UST sy stems within 30 d ays of test date. A. General Information Facility Name: Pacific Bell Telephone Co. dba AT&T California Building No.: UE042 Site Address: 345 N. SAN JOAQUIN City: Stockton Zip: 95202 Facility Contact Person: Connie Mitchell Contact Phone No.: 209-474-4022 Make/Model of Monitoring System: Veeder Root TLS -350 Date of Testing/Servicing: 7/18/2011 B. Inventory of Equipment Tested/Certified Check the aonrooriate boxes to indicate specific eauinment inspected/serviced: The Tank ID: UE042U001 Tank ID: In -Tank Gauging Probe. Model: 847390-109 In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 794390420 r Annular Space or Vault Sensor. Model: F Piping Sump/ Trench Sensor(s). Model: 794380-208 r Piping Sump/ Trench Sensor(s). Model: Fill Sump Sensor(s). Model: 794380-208 r Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: r Mechanical Line Leak Detector. Model: �- Electronic Line Leak Detector. Model: r Electronic Line Leak Detector. Model: Tank Overfill/ High -Level Sensor. Model: 790091-001 r Tank Overfill/ High -Level Sensor. Model: F 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 ID: r In- Tank Gauging Probe. Model: r In -Tank Gauging Probe. Model: r Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: F Piping Sump/ Trench Sensor(s). Model: Piping Sump/ Trench Sensor(s). Model: F Fill Sump Sensor(s). Model: r Fill Sump Sensor(s). Model: r Mechanical Line Leak Detector. Model: r Mechanical Line Leak Detector. Model: F Electronic Line Leak Detector. Model: r Electronic Line Leak Detector. Model: F Tank Overfill/ High -Level Sensor. Model: r Tank Overfill/ High -Level Sensor. Model: F Other (specify equipment type and model in Section E on Page 2). r Other (specify equipment type and model in Section E on Page 2). Dispenser ID: Dispenser ID: r Dispenser Containment Sensor(s). Model: r Dispenser Containment Sensor(s). Model: F Shear Valve(s). r Shear Valve(s). F Dispenser Containment Float(s) and Chain(s). r Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: F Dispenser Containment Sensor(s). Model: r Dispenser Containment Sensor(s). Model: F Shear Valve(s). r Shear Valve(s). F Dispenser Containment Float(s) and Chain(s). 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) : F System set-up r' Alarm history report Technician Name (print): Victor Guerrero Signature: Certification No.: B36532 License. No: 588098 Testing Company Name: TAIT ENVIRONMENTAL SERVICES Phone No.: 714560-8222 Testing Company Address: 2131 SOUTH DUPONT DRIVE, AN... Date of Testing/Seryicing: 7/18/2011