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Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.watetboard v � � MONITORING SYSTEM CERTIFICATION t For Use By All Jurisdictions Witlun the State of California Authority Cited:Chapter 6.7,Health andSafety Code,Chapter 16,Division 3, Title 23,California Code ofRegulations This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be p DQ3 � 1 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 ofthis form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: Pacific Bell Telephone Co. dba AT&T California Building No.: UE046 Site Address: 907 LINCOLN RD. City: Stockton Zip: 95207 Facility Contact Person: Thuy Tran Contact Phone No.: 209-474-4022 Make/Model of Monitoring System: Veeder Root TLS 350 Plus Date of Testing/Servicing: 3/3/2015 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank Ina Gaug ng Probe. Model 4/716086 In-Tank Gauging Probe. Mod Tank ID: 846390-10 el R Annular Space or Vault Sensor. Model: 794390420/195625 Annular Space or Vault Sensor. Model: R' 794380-208/674465 �r Piping Sump/ Sensor(s). Model: �� Piping Sump/ Sensor(s). Model: F Fill Sump Sensor(s). Model:794380-208/685055 ( Fill Sump Sensor(s). Model: �? Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: F Electronic Line LeakDetector. Model: Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: 790091-001 r Tank Overfill/High-Level Sensor. Model: 3 (specify 9 P tYP g ) (p fy q P n'P g ) Otherequipment ment a and model in Section E on Page 2. �� Other s eci a ui ment a and model in Section E on Pa e 2. ....E Tank ID: Tank ID: r In-Tank Gauging Probe. Model: r In-Tank Gauging Probe. Model: €_ Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: i F Piping Sump/Trench Sensor(s). Model: r Piping Sump/Trench Sensor(s). Model: r Fill Sump Sensor(s). Model: r Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: r Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: _r Electronic Line Leak Detector. Model: � r Tank Overfill/High-Level Sensor. Model: r Tank Overfill/High-Level Sensor. Model: Other(specify equipment type and model in SectionE on Page 2) r Other(specify equipment type and model in Section on Page 2). Dispenser IDDispenser ID r Dispenser Containment Sen sor(s). Model: r Dispenser Containment Sensor(s). Model: r Shear Valv s . r Shear Va1v s . r Dispenser Containment Float(s)and Ch ain(s). r Dispenser Containment Float(s)and Chain(s). �? Dispenser ID: Dispenser ID: 1 F Dispenser Containment Sensor(s). Model: IF Dispenser Containment Senmr(s). Model: F Shear Valve(s). r Shear Valve(s). r Dispenser Containment Float(s)and Chann(s). r Dispenser Containment Float(s)and Chain(s),I� If the facility contains more tanks ordispensers,copy this form.Include information for every tank and dispenser er 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) : System set-up P Alarm history report Technician Name(print): Dan Luck Signature: Certification No.: B35802 License. No.: 588098 Testing Company Name: TAIT ENVIRONMENTAL SERVICES Phone No.: 714560-8222 Testing Company Address: 2131 souTxDveor*rmnv> ANAHQM,CA92806 Date of Testing/Seryicing: 3/3/2015