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9255517888 Line 1 ' � • 11:37:52 09-24-2013 2;12 ®6truirR-FrANr"l. GfJob# 20-592178 Appendix V1 RIEC YVf" MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California c2� �� Authority Cited. Chapter 6.7, Health and Safety Code,Chapter 16,Division 3, Title 23, 15ab hi iiod9 of Regulations ENVIRONMENTAL This form must be used to document testing and servicing of monitoring equipment.A separate certification pr�tegortgri t00ldrspare4tbr 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.The ownerloperator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: PG&E Bldg.No.: Site Address: 4040 West Lane City: Stockton zip: Facility Contact Person: Alex Steele Contact Phone No.; Make/Model of Monitoring System: TLS 350 Date of Testing/Servicall 9118/2013 B. Inventory of Equipment TestedCedifietl Check the appropriate boxes to Indicate Specific equipment ins acted/serviced: Tank ID: Unleaded Tank ID: Diesel ® In-Tank Gauging Probe. Model: MAG 1 © In-Tank Gauging Probe. Model: MAGI ® Annular Space or Vault Sensor. Model: 794390420 ❑ Annular Space or Vault Sensor. Model 7949 .420 IM Piping Sump/Trench Sensoria). Model: 794380-208 © Piping Sump/Trench Sensor(s). Model: 794380.20a3 ❑ FIII Sump Sensoria). Model: ❑ Fill Sump Sensorial Model: ❑ Mechanical Line Leak Detector. Made]: ❑ Mechanical Line Leak Detector. Model: 10 Electronic Line Leak Detector Moder 848480 10 Electronic Line Leak Detector Model: 848480 E3Tank Ove1511/High-Level Sensor. Model: ❑ Tank Overfill!High-level Sensor. Model: ❑ Other L3R2cil equipment type and model In Section E on29e 2. CIOther(Specify equipment a and model in Section E on Pae 2), Tank ID: Waste 011 Tank ID: ❑ fn-Tank Gauging Probe. Model: ❑ In-Tank Gauging Prone. Model: ® Annular Space or Vault Sensor. Model: 794 90420 ❑ Annular Space or Vault Sensor. Model: © Piping Sump/Trench Sensoria). Model 794380-208 ❑ piping Sump/Trench Sensoria). Modal: ❑ FIII Sump Sensoria). Model: ❑ FIII Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model; ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: 13 Tank Overall l High-level Sensor, Mode: 794190420 ❑ Tank Over0il/High-Level Sensor. Model: ❑ Other(sped equipmentlype and model in Sectlon E on Pae 2. ❑ Other(sDecVv eculinment and model In Section E on Page 2). [Olspeniser ID: Unleaded#1 Dispenser ID: Unleaded#2 Dispenser Containment Sensoria). Model: 794380-206 IN DlspenserContainmentSensor(s), Model: 794380-208 hearValve(s). ® ShearValve(s). Dispenser Containment Floats and Chain(s). ❑ Dis enser Containment Floats and Chains. Dlsper lD: DleselDispenser lD: IX Dispenser Containment Sensor(s). Model: 784380-205 ❑ Dlspen4er Containment Sen qs). Model: Shear Valve(s). ❑ ShearVaNe(s). ❑ Dispenser Containment Floats and Chain a. ❑ Dispenser Containment Floats and Chains. Dlsper l0: Dispenser ID: ❑ Dispenser Containment Sensoria). Model: ❑ Dispenser Containment Sensor(s). Model; ❑ Shear Valve(s). ❑ Shear Valve(al ❑ Dispenser Comainment Floa s antl Chains ❑ Dis enser Containment Floahsl and Chants). If the facility contains mom tanks or dispensers,copy this form.Include information for every tank and dispenser at the radlity. 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 ® Alarm history report 9 l Techndan Name(print): Jose Carrasco Signature Ceniraatton No.: 835934 License.No.: 220793 Testing Company Name: Gettler-Ryan Inc. Phone No.: 925-551-7555 Testing Company Address: 6747 Sierra Court Suite J,Dublin,Ca.94568 Date of Testirlg/Servicing: 9/18/2013 Monitoring System Certification Page 1 of 4 12107 )