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ONIT ING SYSTEM CETIFI TION 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 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. 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: AT&T/SBC GEO PAR # UE -058 CLLC Code: TRACCAI I Site Address: 10 E. 12TH STREET City: TRACY Zip: Facility Contact Person: TOM WILLIAMS Contact Phone No.: 209-466-1010 Make/Model of Monitoring System: VEEDER-ROOT TLS -350 Date of Testing/Service: 7/19/06 B. Inventory of Equipment Tested/Certified Check the ro riate boxes to indicatespecific equipment ins ected/serviced: Tank ID: 1232 Tank ID: ®In -Tank Gauging Probe: Model: 847390-107 ❑In -Tank Gauging Probe: Model: ®Annular Space or Vault Sensor: Model: 794390-420 []Annular Space or Vault Sensor Model: ®Piping 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: ®Tank Overfill/High-level Sensor: Model: 790991-001 []Tank Overfill/High-level Sensor: Model: ®Other, Specify equip. t e and model in Section E on Page 2 ❑Other, S2ecify equip. t e and model in Section E on Page 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, S ecif e ui . type and model in Section E on ELge 2 ❑Other, S2ecify equip. t e and model in Section E on PaLe 2 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 Chain(s) ❑Dis enser Containment Float(s) and Chain(s) 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 Chain(s) ❑Dis enser Containment Float(s) and Chain(s) 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 Chain(s) ❑Dis enser 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 tacnny. 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 -gene ting such reports, I have also attached a copy of the report; (check all that apply): ® System set- Alarm history report Technician Name (Print): MICHAEL L. STRAWN, II Signature: Certification No.: 006-05-3018 License No.: 5880 Testing Company Name: TAIT ENVIRONMENTAL SYSTEMS Phone No.: (714) 560-8222