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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 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: PACIFIC BELL GEO PAR # UE -058 CLLC Code: TRACCAt t Site Address: 10 E. 12TH STREET Facility Contact Person: KATHY HALLIGAN City: TRACY Contact Phone No. Make/Model of Monitoring System: VEEDER ROOT TLS -350 B. Inventory of Equipment Tested/Certified Ch ck the a ro riate boxes to indicate s ecific equipment ins ected/serviced: Zip: 209-474-4514 Date of Testing/Service: 8/11/03 I Tank ID: 1232 Tank ID: ZIn-Tank Gauging Probe: Model: 847390-107 ❑In -Tank Gauging Probe: Model: ZAnnular Space or Vault Sensor: Model: 794390-420 ❑Annular Space or Vault Sensor Model: ZPiping Sump/Trench Sensor (s): Model: 794380-352 ❑Piping Sump/Trench Sensor (s): Model: ZFill 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: ZTank Overfill/High-level Sensor: Model: 790091-001 []Tank Overfill/High-level Sensor: Model: ❑Other, S ecif a ui a and model in Section E on Page 2 ❑Other, S ecif a j! . e and model in Section E on Pa e 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 Page 2 ❑Other, SpeciLy equip. e 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). ❑Dis enser Containment Float(s) and Chain(s) ❑Dis enser Containment Floats) and Chain(s)- hain(s).Dispenser DispenserID: 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). [-]Dispenser 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 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, I have also attached a copy of the report; (check all that apply): Z System set-up Z Alarm i tory, rejM--- Technician Name (Print): CRAIG BLOCK Signature: Certification No.: 1356 License No.: 8098 Testing Company Name: TAIT ENVIRONMENTAL SYSTEMS Phone No.: (714) 56T-8222