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Appendix VI RECEIVED (Copies of Monitoring System Certification form and USTMonitoring Plot Plan available athttp:f,'wwtiv.wate rboards.ca.2(n .) 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 ofRegulat� VIRPNMENTAL This form must be used to document testing and servicing ofmonitoring equipment. A separate certification or report mustspr�arat_-R $ka r 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 ofthis form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: Pacific Bell Telephone Co dba ATT California Facility [D: UE042 Site Address: 345 N. San Joaquin City: Stockton Zip: 95202 Facility Contact Person: Thuy Tran Make/Model of Monitoring System: Veeder Root TLS 350 Plus Contact Phone No.: 209-532-3447 Date of Testing/Servicing: 2015/08/20 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: UE0420001 Tank ID: UE0420005 ;❑i� In -Tank Gauging Probe. Model: 847390-109/097046 ❑ In -Tank Gauging Probe. Model: ❑X Annular Space or Vault Sensor. Model: 794390-420/092808 Annular Space or Vault Sensor, Model: 794380-344/995867 ¢ ' N Piping Sump/ Trench Sensor(s). Model: 794380-208/794946 ❑ Piping Sump/ Trench Sensor(s). Model: FX Fill Sump Sensor(s). Model: 794380 208/917920 "Ej 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 l hlig790091-001 h -Level Sensor. Model: ❑ "fankOverfill /High -Level Sensor. Model: ' � Other (spectfi equipment type and model in Section E on Page 2). ❑Cther (specifyequipmenttype and model in Section E on Page 2). .? Tank ID: UE0420006 Tank ID: ❑ In -Tank Gauging Probe. Model: ;❑ In-TankGauging Probe. Model: 3E�I €❑X Annular Space or Vault Sensor. Model: 794380-344/995705 r)❑ Annular Space or Vault Sensor. Model: ; ❑ Piping Sump/ Trench Sensor(s). Model: ii i ❑ Pipin Sunmp/ Trench Sensor(s). Model ? �❑ Fill Sump Sensor(s). Model: s❑ Fill Sump Sensor(s). Model: ?j (❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: p Electronic Lume Leak Detector. Modeli ❑Electronic Luce Leak Detector. Model: Tank Overfill / High -Level Sensor. Model 1❑ Tank Overfill / High -Level Sensor. Model: ??�z 1❑ Other (specify equipment type and model in Section E on Page 2). 11❑ Other (specify equipment type and model in Section E on Page 2). I! Dispenser ID: 8j Dispenser ID d 110 Dispenser Containment Sensor(s). Model: 1 i� ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). 11❑ Shear Valve(s). t�❑ Dispenser Containment Float(s) and Cham(s) i 11❑ Dispenser Containment Float(s) and Ch am(s) € Dispenser ID: 11 Dispenser ID. 110 Dispenser Containment Sensor(s). Model i 1 ❑ Dispenser Containment Sensor(s). Model:, }❑ Shear Valve(s). � , ❑ Shear Valve(s). 3� ❑ DlspcnscrContainment Float(s)andCham(s) ❑Dispenser Containment Float(s)and Cham(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' eheckfists)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, 1 have also attached a copy of the report; (check allthatapply) : System set-up Q Alarm history report Technician Name (print): Dan Luck ID" /j_. Signature: ^r+�i Certification No.: 835802 License. No.: 588098 Testing Company Name: TAIT ENVIRONMENTAL SERVICES Phone No.: 714560-8222 Testing Company Address: 2131 SOUTH DUPONT DRIVE, ANAHEINI,,CA92806 Date of Testing/Servicing: 2015/08/20