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01/24/2005 15:17 209942#RMG PG&E MKTG STKN PAGE 02 SYSTEM CERTACATION ,For Use BY All Jurisdictions Within the,State of California Authority Cited. Chapter 6.7 Health and Safety Code;Chapter 16,Division 3, Title 33,Cal forma Cade of,(7egui Wons Thisform must be used to document testing and servicing of monitoring equipment: If mote than one monitoring system control panel is installed at the facility, a se ap rate cell ification or report must be rime Pared or each monitoring„system control Hanel by the technician who performs the work A cosy Of this form must be provided to the tank system owner/operator, The OWAer/operator must submit a copy of this form to the local agency regulating TIST systems witbin 30 days of test date. Instructions are printed on the back ofthis page: A. General Information r Facility Name: �' Bldg.No:; Site Address: 'YO'f O II f City _j�4y paK Zip: Facility Contact Person:—._ E- i C'l.. Z O 10� Contact Phone No.: MakeiModelofmonitoringSystem: S.Sp Dale of Testing/Servicin� Ll dY/ oS �yC;'�✓i H'eda sera B.. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicateifre enuipment in serviced: Tank ID r p Tank TD- 9 7a-Tank Gaugiag probe. Model: Q Ia Tank Cmug tS Ptob¢: Model: W Annular Space or Vault sensor. Model: .o Q Aunulu Spnre or Vault Sensor. Model. Sr Piping sump/Trench Seasor(s). Model: L/ Q Piping Smhp l Trench sewox(s)- Model: Cci�ria S”seusor(s). Model: CI pin siuup sensor(s). Model: 1m - ivleeNtnical Lina Leak Dctector, :Model: L! U Mechanical Linel oak Detector. Model . O Hlectmnic.Line Leak Detector. .Model: Q Electronic Line LeskDetedw. Model: Cl Tank Ovefll/ IA-Level Sensor. Model: 0 Tank Oved11/ITrgh-Level Sensor. Model: WDispeaser Contaimtent Seosar(s). Model: 3'7./ . Cd Dispenser Containment Seusor(s). Modch El Shear Valve($), 0 Shear'Valve(s). ❑Dispensercantaimmpt Tient(s)and Chain(s). Q Dispenser Cootwimmmt Fleat(s)and Chain(19)- Ll Other if meat a and on in SacticmE on Pa 2 . Cl Other ec' td meat s and model in section E on Pig!2. Tank TD: Tank ID: Cl le-Tank Gangmgprolm Model: ❑ Tn-T=kG a'ug,ngPzohe. Model:' . ❑..AattuIpr Space or Vault Seasmu Model: Cl Annular Space or Vault Sensor. Model: . _❑ Piping Sump I Trench Seusor(s)_ ModeL- - ❑piping Sump I Trench Seosor(s). Model: 13 Fill Sump Sensor(s). Model: O Fill sump Sensor(s)- Model; C.1Mechanical Line Leak Detector. Model: UAlechamicadLine,Leak DetecWL Model: . 0 Electronic Line Leak Detector, Model: Q Electronic Line Teak Detector. Model: Tank Ovedrlt/High Lend Sensor. Mom: ❑ Tack Oc ll/High-Level Sensor. Model: 0Dispense Containment Sensor(s). Model: QDispeusercontammentSensot(s). Model' 13Sfiear Valve($), CI Shear Valvc(s). Cl Dispenser Contaimuptt Float($)and Chain($). Q Dispenser containwaut Floats)and Chain(s). ❑ Outer ec' of metrt a�d wodeI ire Seclion L-on P 2. CI Other ni meat tjTe and model in Section P on pa 2: C. Certificetl0n -I certify that the equipment identWxed in this document was inspected/serviced in accordance with the manufacturers' guidelines, Attached to this Certification is informat-rod (e.g. manufacturers' checklists) iaec�ssary to verify that this information is correct and a Site Plan sho%1ug the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attached a copy of the(check all that apply): Q System set-up report; �i ❑Alarm history report Technician Name(print): Cert/Lic.No.: oar-a5- Testing Company Name: GAG- %d�fT Phone Na,; 53n 7St/P7 v