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0 Appendix V1 41 RECEIVEL (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at h1tp:/,,"wwv,,,.watc qy,2,5o2016 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Withbi the State of California Authority Cited. Chapter 6.7,Health and Safety Ode;Chapter 16,Division 3, Title 23,California Code ofRegidatENVIRONMENTAL APTA4C%1— This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must bVW;Vdntof : for each - monitoring system control panel by the technician who perfornis the work. A copy of this tbrni must be provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating LIST systems within 30 days of test date. A. General Information Facility Name: Pacific Bell Telephone Co dba ATT California Facility ID: 00010 Site Address: 1812 Coley Ave. City: Escalon Zip: 95320 Facility Contact Person: Thuy Tran Contact Phone No.: 209-474-4022 Make/N/Iodel 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: TankID: UG01OU001 11 Tank ID: HFX In-Tank Gauging Probe. Model: 847390-107/731089 In-Tank G auging Probe. Model: fl X Annular Space or Vault Sensor. Model: 794390-420/490104 Annular Space or Vault Sensor. Model: 11 3 X Piping Sump/Trench Sensor(s). Model 794380-208/515978 Piping Sump/Trench Sensor(s). Model: 11❑ Fill Sump Sensor(s). Model- Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model- ❑Mechanical Line Leak Detector. Model- 11❑ p. Electronic Line Leak Detector. Model: lir❑Electronic Line Leak Detector. Model: R� Tank Overfill/Hi-h-l-evel Sensor. Model: 790091-001 11E]Tank Overfill/H�.gh-Level SensoModel:❑Other(specify euipment type and model in Section E on Page 2). Other(specify equipment type and model in Section E on Page 2). H Tank Tank ID . ❑ In-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: liE] Annular Space or Vault Sensor. Model: ❑Annular Space or Vault Sensor. Model: is ❑ Piping Sump/Trench Sensor(s). Model: ❑Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: El Fill Sump Sensor(,,). Model: F] Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector, Model: ❑Electronic Line Leak-Detector. Model: ii Tank Overfill/High-Level Sensor. Model: —]Tank Overfill/High-Level Sensor. Model: NEI Other(specify equipment type and model in Section E on Page 2). Other(specify equipment type and model in Section E on Page 2). ❑ 11 Dispenser ID: Dispenser ID: IiM Dispenser Containment Sensor(s). Model: 11:1 Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). Shea,Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). 'E]Dispenser Containment Float(s)and Chain(s). 11 Dispenser ID: Dispenser ID: Dispenser Containment Sensor(s). Model: IT-1Dispenser Containment Sensor(s). Model: Shear Valve(s). 11F_1 Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). 0Dispenser Containment Float(s)and Ch ain(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 P lo t Plan showing the layout of monitoring equipment For a ny equipment capable of generating such reports,I have also attached a copy of M\7 M\7 the report;(check all that apply) : 1^1 System set-up 1^1 Alarm history report Technician Name(print): John Cascio Signature: P049 e4je,61 Certification No.: B35337 License. No.: 588098 Testing Company Name: TAIT ENVIRONMENTAL SERVICES Phone No.: 714560-8222 Testing Company Address: 2131 SOUTH DUPONT ERFVE,AW11EINI,CA92906 Date of Testing/Servicing: 02-18-2016