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Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://w rd E Wn MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California APR 2014 Authority Cited. Chapter 6 7, Health and Safety Code; Chapter 16, Division 3, Tule 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or reporting o monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the ore�� e owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. Hr each HEALTH A. General Information Facility Name: Pacific Bell Telephone Co. dba AT&T California Site Address: 1812 COLEY AVE. City: Facility Contact Person: Dave Dube Make/Model of Monitoring System: Veeder Root TLS -350 plus B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment Tank ID: UGOl0U001 Building No.: UG010 Escalon Zip: 95320 Contact Phone No.: 2091374-4022 Date of Testing/Servicing: 3/26/2014 inspected/serviced: Tank ID: F In -Tank Gauging Probe. Model: In -Tank Gauging Probe. Model: 847390-103/731089 Annular Space or Vault Sensor. Model: 794390420/490104 r Annular Space or Vault Sensor. Model: Piping Sump/ Trench Sensor(s). Model 794380-208/515978 F Piping Sump/ Trench Sensor(s). Model: Fill Sump Sensor(s). Model: F Fill Sump Sensor(s). Model: F Mechanical Line Leak Detector. Model: F Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: F Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: 790091-001 r Tank Overfill / High -Level Sensor. Model: Other (specify equipment type and model in Section E on Page 2). ; F Other (specify equipment type and model in Section E on Page 2). Tank ID• Tank ID: F In -Tank Gauging Probe. Model: In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: F Annular Space or Vault Sensor. Model: Piping Sump/ Trench Sensor(s). Model: F Piping Sump/ Trench Sensor(s). Model: Fill Sump Sensor(s). Model: F Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: F Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: F Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: F Tank Overfill / High -Level Sensor. Model: F Other (specify equipment type and model in Section E on Page 2). F Other (specify equipment type and model in Section E on Page 2). Dispenser ID Dispenser ID: Dispenser Containment Sensor(s). Model: F Dispenser Containment Sensor(s). Model: Shear Valve(s). F Shear Valve(s). F Dispenser Containment Float(s) and Chain(s). F Dispenser Containment Float(s) and Chain(s). Dispenser ID { Dispenser ID Dispenser Containment Sensor(s). Model: F Dispenser Containment Sensor(s). Model: F Shear Valve(s). r 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) : System set-up F Alarm history report Technician Name (print): Victor Guerrero /� "— IN Signature: } Certification No.: B36532 License. No.: 588098 Testing Company Name: TAIT ENVIRONMENTAL SERVICES Phone No.: 714560-8222 Testing Company Address: 2131 soUTHDUPONTEMF ANAMNLCA92806 Date of Testing/Servicing: 3/26/2014