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Z® d %L6 6LZ0 bVE SEG 9T:ST b®0Z-02—HHW Aft 0 1P 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 of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be eared 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. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: PACIFIC BELL _ GEO PAR# UE-058 CLLC Code: TRACCAt t Site Address: 10 E. 12TH STREET City: TRACY Zip: Facility Contact Person: KATHY HALLIGAN Contact Phone No.: 209-474-4514 Make/Model of Monitoring System: VEEDER ROOT TLS-350 Date of Testing/Service: 8/11/03 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific a ui ment ins ected/serviced: Tank ID: 1232 Tank ID: ®ln-Tank Gauging Probe: Model: 847390-107 [1 In-Tank Gauging Probe: Model: ®Annular Space or Vault Sensor: Model: 794390-420 []Annular Space or Vault Sensor Model: SPiping Sump/Trench Sensor(s): Model: 794380-352 []Piping Sump/Trench Sensor(s): Model: ®Fill Sump Sensor(s): Model: 794380-352 ❑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: STank Overfill/High-level Sensor: Model: 790091-001 []Tank Overfill/High-level Sensor: Model: ❑Other,Specify e e and model in Section E on Page 2 ❑Other,Specify aqui a and model in Section E on Pae 2 Tank ID: Tank ID: []In-Tank Gauging Probe: Model: ❑In-Tank Gauging Probe: Model: []Annular Space or Vault Sensor: Model: ❑Annular Space or Vault Sensor Model: ❑Piping Sump/Trench Sensor(s): Model: ❑Piping Sump/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 Model: ❑Electronic Line Leak Detector Model: ❑Tank Overfill/High-level Sensor: Model: []Tank Overfill/High-level Sensor: Model: ❑Other,Specify aqui a and model in Section E on Pa e 2 ❑Other,S eci eq!uip.lTe and model in Section E on Pa e 2 Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensor(s): Model: ❑Dispenser Containment Sensor(s): Model: ❑Shear Valve(s). ❑Shear Valve(s). ❑Dig enser Containment Float(s2 and Chain(s) ❑Dis enser Containment Float(s)and Chains Dispenser ID: Dispenser ID: []Dispenser Containment Sensor(s): Model: []Dispenser Containment Sensor(s): Model: ❑Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Float(s)and Chains ❑Dis enser Containment Float(s)and Chain(s)___ Dispenser ID: I Dispenser ID: ❑Dispenser Containment Sensor(s): Model: ❑Dispenser Containment Sensor(s): Model: ❑Shear Valve(s). ❑Shear Valve(s). ❑Di enser Containment Floats and Chain(s) ❑Dis enser Containment Float(s)and Chain(s) *Ifthe 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 correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,l have also attached a copy of the report;(check all that apply): N System set-up N Alarm_ i tory e� r Technician Name(Print): CRAIG BLOCK Signature: Certification No.: 1356 License No.: 8098 Testing Company Name: TAIT ENVIRONMENTAL SYSTEMS Phone No.: (714)5W-8222 zoom N SHOIA113S ?IhOUAN 6LZ0 6VZ SZ6 Xyd V0:9T SIIZ ti0/0£/£0