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r Appendix Vi (Copies Of monkorft SY i form and UST Monittift Plot Plan avallatile at http:/Miww. ca.9ov) Monitoring System Certification For Use By AN J *V*i the State of Caftmia A Cited:Chapter 6L 7,Heald►and Safety Code:Chapter t f DMdon 3. Tile 23,CaNbtnb Code of ROPAOM This form must be used 10 dmune nt testing and servicing of A or report acral be for each rrtonttorirng system oonHral panel by the who performs the stunk.A o2n d tlgs must be to the tank owns .The wArroer/operator must submit a cwpy d this kam to the kcal agency UST systems wdW 30 d dots. A.General Information Facility.Pacific Bell Telephone Co.dba AT&T California GEO PAR#UE058 Address:10 E.12TH ST. OW.TRACY Zi :95376 Facility Contact Person:Connie Mitchell Contact Phone No:2094744022 Make/Model of Monitoring m:Veeder Root TLS-350 Service Date:05/10/2011 B.Inventory of Equipment Te ed Check the appropriate bozos to indicate specific equipment Nps . Tank ID: UE0580002 Tank ID: ®in-Tank Gaiging Probe Model:847380-107 ❑WT6,* Probe Model: ®Annular Space or Vault Sensor Model:794390420 ❑Annular Space or Vault Sensor Model: ®Piping Sump/Trench Sensors) Model:794380-208 ❑FOv Stapp/Trench Sensor(s) Madel: ®Fill Sump Sensor(s) Model:794.3W208 ❑F81 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:79W91-001 ❑Tank Overfill/High Level Sensor Model: ®Other(Specify WlUiWnwd type and model in Section E on Page 2) ❑Other(Spa*OWOnant type and model in Section E on Page 2) TanklD: TanklD: ❑In-Tank G&WV Probe Model: ❑In-Tank Gauging Probe mel: ❑Annular Space or Vault Sensor Model: ❑Annular space or Vault Sensor Model: ❑Piping Sump/Trench Swum(s) Model: ❑Piping Swnp/Trench Swwor(s) ❑FII Sump Sensor(s) Model: ❑Fill Sump Sensor(s) Model: ❑Mechankel tete Leak Detector Model: ❑Mechanical Line Leak Detector Model: ❑Electronic Line Leak Detector Model: ❑Electronic Line Leak Wiector Model: ❑Tank Overlill/High Level Serum Model: ❑Tank Overfill/ High Level Seng Model: ❑Other(Spedy OWPmnt type and modal in Section E on Page 2) ❑Other(Specify equipment Mie and model in Section E on Page2) Dispenser ID: Dispenser ID: ❑Dispensar Containment sensor(s) Madel: ❑Dispenser Containment Sensors) Model: ❑Shear Valve(s) ❑shearYaws) ❑Dispenser Contairwrient Fost(s)and Chains) ❑ Fkags)and c (s) Dispenser ID: Dispenser ID: ❑Dispenser Containers sensors) Model: ❑Dspenw Containment Sexnsor(s) Model: ❑Shear Va"s) ❑Shear VaMs(s) ❑Dispenser Containment Roat(s)and Chain(s) ❑Dispenser Floats)and Chain(s) Dispenser ID: Dispenser ID: ❑Dispenser Containment mss) mel: ❑Dnspenser Containment Sensors) Model: ❑shear valve(s) ❑shear Valve(s) ❑Dispenser Containment noat(s)and Chains) ❑Dispenser Containment Flost(s)and Chain(,) if the facility contains more tanks or dispensers,oopY this form.Include infimmation for every tank and dispensair at the facility- C. Certification-I cerwy that the M this document was arts serviced in manufacturers'guidelines. b Certtfcaton k irtfonnation(e.g.man durers'di4tddiiists) that this Information is corred and a not Plat showing the layout of man ng For any eqUOTIOnt necessary to verily, generating such repots,l have also attached a copy of the report;(check aH the apply): We of Systom so Technician Name Print:Victor Guerrero ® '� ®Harm history repprt S' Certification No:836532 License No:588098 Testin Com n Nartte:TAIT ENVIRONMENTAL SERVICES Testin 3 Companv Address:2131 Sotrtll Du t Drive Anaheim CA 92806 Dorcas of Testi:(7141560-8222 Monitoring System Certifmation Page t of 4 05/10/2011 12/07 t 2/21/07