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miloputrurA v® (Copies of Monitoring System Ce . tion form and UST Monitoring Plot Plan availabl http://www.wateftards.ca.gov) 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 ownerloperator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility: AT&T Co ration GEO PAR # UE231 Address: J110 W. Tumer Rd. 95242 City: Lodi r&595242 Facility Contact Person: Connie Mitchell Contact Phone No: 209-598-5155 Make/Model of Monitoring System: Veeder Root TLS -350 Service Date: 06/17/2009 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicate specific equipment Inspectediserviced: Tank ID: UE231UO01 _ Certification No: 635665 _ License No: 58809 Tank ID: _ I Phone No: 714 560-8222 ® In -Tank Gauging Probe Model:846390-109 ❑ 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:794380-208 ❑ 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:790091-001 ❑ Tank Overfill / High Level Sensor Model: ® Other (Specify equipment type and model In Section E on Page 2) ❑ Other (Specify equipment type 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 (Specify equipment type and model in Section E on Page 2) ❑ Other (Specify equipment type and model In Section E on Page 2) 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) ❑ Dispenser 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) ❑ Dispenser 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) ❑ Dispenser 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): ® Sy tem set-up Alarm history report Technician Name (Print): Christopher Derosier Signature _ Certification No: 635665 _ License No: 58809 Testing Company Name: TAIT ENVIRONMENTAL SERVICES _ I Phone No: 714 560-8222 Testing Company Address: 2131 South Dupont Drive Anaheim CA 92806 JDate of Testing/Servicing: 06/17/2009 Monitoring System Certification Page 1 of 4 12107 1 2/21/07