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Appendix VI f i-1%EivED (Copies of Monitoring System Certification form and DSTMonitoringPlotPlan available at lrttp:!/i�-w�v.watcr oar s.ca.gov.) MONITORING SYSTEM CERTIFICATION FEB 2 5 2096 For Use By All Jurisdictions Within the State of California Authority Cited.Chapter 6.7,Health and Safety Code;Chapter 16,,Division 3, Tale 23,California Code ofRegulations �� This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be L monitoring system control panel by the technician who perforans the work. A copy of this tbrm must be provided to the tank systeMF,, iii b�tgTVP1T oNmer/operator must submit a copy ofthis form to the local agency regulating USTsystems within 30 days of test date. A. General Information Facility Name: Pacific Bell Telephone Co dba ATT California Facility ID: 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: 02-18-2016 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank I��. D, UE046U002 Tank ID: e..._ _w__. r _ :•.� ❑x In-Tank Gauging Probe. Model: 846390-104/716086 €€❑In-Tank Gauging Probe. Model `M Annular Space or Vault Sensor. Model: 794390-420/195625 ®Annular Space or Vault Sensor. Model: €❑X Piping Sump/Trench Sensor(s). Model: 794380-208/674465 �❑piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: 794380-208/685055 ❑Fill Sump Sensor(s). Model: t l Mechanical Line Leak Detector. Model i❑Mechanical Line Leak Detector. Model: ii ❑ Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: 3 Tank Overfill/High-Level Sensor Model: Non Veeder Root i? ;� e , Tank Overfill/High I evel Sensor. Model: ❑ Other(spent} 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: J In-Tank Gauging Probe. Model: i}❑In-Tank Gauging Probe. Model: 4 Annular Space or Vault Sensor. Model: ii❑Annular Space or Vault Sensor. Model: i❑ Piping Sump/Trench Sensor(s). Model: ❑Piping Sump/Trench Sensor(s). Model: (i _❑ Fill Sump Sensor(s). Model: I,❑Fill Sump Sensor(s). Model: i= ❑ Mechanical Line Leads Detector. Model: ❑Mechanical Line Leak Detector. Model: ig❑ Electronic Line Leak Detector. Model: i;❑Electronic Line Leak D ete ctor. Model: ❑ Tank Overfill/High-Level Sensor. Model ❑Tank Overfill/High-Level Sensor. Model: ❑ Other(specifi equipment type and model in Section E on Page 2) ❑Other(specify equipment tvpe and model in Section E on Page 2) ._ Dispenser ID: Dispenser ID: _❑ Dispenser Containment Sensor(s). Model: J❑Dispenser Containment Sensor(s). Model: i ❑ Shear Valve(s). ;❑Shear Valve(s). ? ❑ Dispenser Containment Float(s)and Chains) ❑Dispenser Containment Float(s)and Ch ain(s) Dispenser ID: Dispenser ID: :,❑Dispenser Containment Sensor(s). Model: 11❑Dispenser Containment Sensor(s). Model: i ❑ Shear Valve(s). t;❑Shear Valve(,). ❑ 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 correctand 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) : Q System set-up Q Alarm history report Technician Name(print): John Cascio Signature: Certification No.: B35337 License. No.: 588098 Testing Company Name: TAIT ENVIRONMENTAL SERVICES Phone No.: 714560-8222 Testing Company Address: 213i soUTnDUPONTnRIVH,ANAHE[M CA92806 Date of Testing/Servicing: 02-18-2016