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0 Appendix V1 0 (Copies of Morwitoring System CertilicOw form WW UST IMMINOIN Plot Plan avallable at htW&w-weWdxoardsca.QOV) Monitoring System CoMmUon For Use By AN Affieftdons Mhb7 Me State of C~W A Ownty Cb& Chapter 6.7. HMO and Safety Code,* Chapter 16, DAWOn A TNO 23, COWnis COCIR Of ftufsff" This form must be used to document tuft and swvmkV of morvilarirg I A owgkdbn or report must be prepared for each the technician who Perform " woezc be prwided to the tank system omw1operStOr. The ==2Ow%Mmw*bn*P= Of Oft 9bM 10 the local agency regUlaft systerns Within 30 days of lest date. A- General Infonnation Facility: Pacft Bell Telephone Co. dba AT&T Caldomia GEO PAR # UE042 Address: 345 N. SAN JOAQUIN City: STOCKTON Zi :95202 Facility Contact Person: Connie Mitchell Contact Phone No: 209-474-4022 Make/Model of Monitoring System: Veeder Root TLS -350 Service Date: 05A3/201 I B. Inventory of Equipment Tested/Certified Char* Om annrmwiate hazas to Indicate amselfic emlimmd Tank ID: UE042UOOI Tank ID: 9 In -Tank Gaging Probe Modei:847390-I09 ❑ In Tank Gauging Probe Model: • Annular Space or Vault Sensor Model:794390-420 ❑ Annular Space or Vault Sensor Model: • POM Sump I Trench Sensor(s) -Model-794380-208 0 Piping Suff0p I Trench Ser%sor(s) Model: Fill Sump Sensor(s) Model:794380-208 0 Fill Sump Sensor(s) Model: ❑ Mechanical Line Leak Detector Model: [] Mechanics! Line to* Detector Model: El Electronic Line Leak Detector Model- 0 Electronic Line Leak Detector Model: • Tank OverN / High Level Sensor MOC101-0thef [I Tank Overfill I High Level Sensor Mom: • Other (Specify equipment type and ffKKIW In Section E on Page 2) E] Other (Specify equipaient type and model In Section E on Pap 2) Tank ID: Tank ID: F1 hi -Tank Gauging Probe Model: ❑ Irv -Tank GaLQft Probe Model: ❑ Annular Space or Vault Sensor Model: ❑ Annular Spam or Vault Swam Model: ❑ PiphV Surnp I Trench Sensor(s) Model: C] Piping; Sump I Trench Sernor(s) mom: El F -d! Sump Sensor(s) Model: [--] Fill Sump Senscr(s) Model: F-1 Mechanical Line Leak Detector Model: 0 Mecharvical Line Leak Detector Model: 0 Electronic Lim Leak Detector Model: 0 Electronic Line to* Detector Model: [I Tank Overfill / High Level Sensor Model: [I Tank Overfill / High Level Sensor Model: C1 Other (Specify equipment type and model in Section E an Page 2) E] Other (Specify eWonent type and model In Section E on Page 2) Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s) Model: ❑ Dispenser Contsinmeni: Serwor(s) Model: ❑ Shear Vak*s) ❑ Shear Valve(s) El Dispenser Containment Floats) and Chain(s) ❑Dispenser Containment Float(s) and Chains) Dispenser ID: DisDenser ID: 0 Dispenser Containment Sensor(s) Model: [I DWpenser Contakwnent Sensor(s) Model: rl Show Valve(s) El show vows) Ej Dispenser Containment Ftwkt(s) and Chain(s) [I Dispenser Contakwnent Roags) mid Chains) Dispenser ID: DispenserID: El Dispenser CwftWrwt Sensw(s) Modal: 0 Dispenser Containmerd Sensor(s) model: El Shear Valve(s) ❑ Shear Valve(s) 0 Dispenser Containment Floags) and Chaln(s) ❑Dispenser Contairwrierd Roags) and Chale(s) * If the kKft contains mom tanks or dbperwers, copy this form. Include inlimmfion for every tank and dispenser at the facility. C. Certification- I certify that the Identified In this document was rviced In accordance with the man ftckwem* guldellnes. ;QQOtqO"w,7 Is Information (e.g. chmMIM) necessary to verffy that= Information Is cormcl: and a Plot Plan -------the layout ofnxm*wtngeqtdpotm For arty equiprIlent capable at generating such fopoft, I have also attached a Dopy the report; (check all VW apply}: 193vatemlset-w — NAlannhironoit Technician Name (Print): Vidor Guerrero Si nature: Certification No: 836532 I License No: 588098 Testing Company Name: TAIT ENVIRONMENTAL SERVICES IPhone No: (714) 560-8222 ji Testing Company Address: 2131 South Du Drive Anaheim CA 92806 1 Date of Testi ng/Service na: 05K13/201 Moriftring System Cefflfication Page I of 4 12W 1 2121/07