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Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at l€tp:;%www.watenfsoards.ca.gov .) MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority Cited. Chapter 6.7, Health and Safety Code, Chapter 16, Division 3, Title 23, California Code ofRegulations This form mustbe used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each 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 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.: UG010 Site Address: 1812 COLEY AVE. City: Escalon Zip: 95320 The Facility Contact Person: Gary Chi mienti Contact Phone No.: (925) 468-8103 Make/Model of Monitoring System: Veeder-Root TLS -350 plus Date of Testing/Servicing: 4/11/2013 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: kGau Tank ID: UG 01OU001 Tank ID: ul Gauging Probe Model. 847390-103/731089 In-TanIn-Tank Gauging Probe. Model. Annular Space or Vault Sensor. Model: 794390-420 / 490104 Annular Space or Vault Sensor. Model: ?= r 794380-208 / 515978 ak Piping Sump/ Trench Sensor(s). Model: � � Piping Sump/ Trench Sensor(s). Model: B F Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model:, Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: < Electronic Line Leak Detector. Model: F Electronic Line Leak Detector. Model: i; Tank Overfill/ High -Level Sensor. Model 790091 001 r Tank Overfill/ High -Level Sensor. Model: i Other (specify equipment type and model m Section E on Page 2).Other (specify equipment type and model in Section E on Page 2) iier.'ttr(sper!:rwwn�.:..,ne an..armee. ...e�rel.e..liPa .iii.. rn.i..�arr .R'. >> lt\' .CHa'kFkFk'YS''��/�.\ �... `S'v°Y:.�G `«L�., `�1�,'3`hSnC`1�?�.+$k%?8'� )fNii�/.i£�✓?.�'. /. Tank ID: i Tank ID: k In -Tank Gauging Probe. Model: F In-TankGauging Probe. Model: F. 1, F Annular Space or Vault Sensor. Model: r Annular Space or Vault Sensor. Model: i? F Piping Sump/ Trench Sensor(s). Model: F Piping Sump/ Trench Sensor(s). Model: F Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: : F Mechanical Line Leak Detector. Model: F Mechanical Line Leak Detector. Model: F Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: r€ F Tank Overfill/ High -Level Sensor. Model: F Tank Overfill / High -Level Sensor. Model: F Other (specify equipment type and model m Section E on Page 2) F Other (specify equipment type and model m Section E on Page 2) ... � Dispenser ID: Dispenser p ID: P r Dispenser Containment Sensor(s). Model: F Dispenser Containment Sensmr s). Model: i F Shear Valve(s). r Shear Valve(s). F Dispenser Containment Float(s) and Chain(s) F Dispenser Containment Float(s) and Chain(s) Dispenser ID: i Dispenser ID: _F Dispenser ContainmentSensogs). Model. �F Dispenser Containment Sen sor(s). Model: l Shear Valve(s). F Shear Valve(s). Dispenser Containment Float(s) and Cham(s). t F 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) : System set-up Alarm history report Technician Name (print): John Cascio_Cz: Signature: -01 Certification No.: B35337 License. No.: 588098 Testing Company Name: TAIT ENVIRONMENTAL SERVICES Phone No.: 714560-8222 Testing Company Address: 2131 soUr'HDnJPONTDMV$ANAHEI-NtCA92806 Date of Testing/Sery icing: 4/11/2013