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Appendix VI (Copies of Monitoring System Ceffication form and UST Monitoring Plot Plan available at http:ltwww.waterboards.ca.gov) Monitoring System Certification For Use By AN Jur isdidms Within tate Siete of Caflfornia Authority Cited. Chapter 6.7, Health and Safety Code, Chapter 16, Division 3, 7"dte 23, Caliibmle Code of Regulations This form nVA9 be used to document testing and servicing of morilto N equipment. A separate certification or report must be prepared for each monitoring m system control p a by the technician who performs the work. A copy of this form must be provided to the tank system ow nerloperator. The copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facil!ty AT&T CoWabon GEO PAR # UE231 Address: J110 W. Turner Rd. City: LodiZi : 95242 Facility Contact Person: Connie Mitchell Contact Phone No: 209-474-4022 Make/Model of Monitoring System: Veeder Root TLS 350 Service Date: 06/02/2010 B. Inventory of Equipment Tested/Certified Check the apprroprfate boxes to Indicate specific eciulprre nt Ins iced: Tank ID:UE231U001 Tank ID: ® in -Tank Gauging Probe Modaf:846390}109 ❑ In -Tanis Gauging Probe mel: ® Annular Space or Vault Sensor Moxdel:7943W420 ❑ Annular Space or Vault Sensor Model: ® Piping Sump / Trench Sensor(s) Model:794380-2013 ❑ Piping Sump / Trench Sensor(s) Madel: ❑ Fin Sump Sensor(s) Model: ❑ Fill Sump Sensor(s) Model: ❑ Mechanical Line Leak Detector Madel: ❑ Mechanical Line Leak Detector Model: ❑ Electronic Line Leak Defector 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 modei in Section E on Page 2) ❑ Other (Specify equipment type and model In Section E on Page 2) Tank ID: Tank lD: ❑ 1n -Tank Gauging Probe Model: ❑ In -Tank Gauging Probe Model ❑ Annular Space or Vault Sensor Madel: ❑ 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 Lite 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 Se-,-or(s) Model: ❑ Shear Valve(s) ❑ Shear Vatve(s) ❑ Dispenser Containment Floats) and Chain(s) ❑ Dispenser Containment Float(s) and Chain(s) Dispenser 10: Dispenser ID: ❑ Dispenser Containment Sensor(s1 Model: ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Va"s) ❑ Shear Valve(s) ❑ Dispenser Containment %ahs) and Chain(s) ❑ Dispenser Containment Fkoags) and Chain(s) Dispenser ID: Dispenser ID: _ _ ❑ Dispenser Containment Sensor(s) Model: ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves) [❑ Shear Valve(s) ❑ Dispenser Containment Float(s) and Chain(s) ❑ Dispenser Containment Float(s) and Chain(s) if the factilly contains more tanks or dispensers, copy this form. Include information for every tank and disj� at ft facility. C. Certification- I certify that the equipment Idardifled In Oft document was I tted/servtcecl in accordance wait the manufacturers' guidelines. Attached to this on Is Inforrnation (e g. rnan rens' checkiltit) necessary to verity that this Information Is correct and a Plot Pian shovdng 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): ®S tent set p root history report Technician Name (Print): Christo pher Derosier Si nature: Certification No: B35665 I License No: 588098 Testing Company Name: TAIT ENVIRONMENTAL SERVICES Phone No: 714 560-8222 Testing Com an Address: 2131 South Duportt Drive Anaheim CA 92806 1 Date of Testing/Servicing: 06/02/2010 Monitoring System Certification Page 1 of 4 12/07 1 2/21/07