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Appendix VI RECEIVED (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.waterb0 Fc�,.gpv 017 MONITORING SYSTEM CERTIFICATION �� 11 �t 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 ofRegt RONME.NTAL HEALTH This form must be used to document testing and servicing of monitoring equipment.A separate certification or report r��nnl, �'e,prep are monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system o UteN r. The 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 Gas and Electric Company Facility ID: PGE095 Site Address: 4040 West Ln. City: Stockton /ih: 95204 Facility Contact Person: Alex Steel Contact Phone No.: Make/Model of Monitoring System: Veeder-root TLS-350 Date of Testing/Servicing: 5-26-2017 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: "Tank ID: Waste Oil Tank ID: ❑ In-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑Annular Space or Vauk Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑Piping Sump/Trench Sensor(s). Model: ❑ 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: ❑Electronic Line Leak Detector. Model: ❑X Tank Overfill/High-Level Sensor. Model: 794390-420 ❑Tank Overfill/High-Level Sensor. Model: ❑X Other(specify equipment type and model in Section E on Page 2). ❑Other(specify equipment type and model in Section E on Page 2). Tank ID: Tank ID: ❑ In-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(,). Model: ❑Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). ❑Other(specify equipment type and model in Section E on Page 2). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑Shear Valve(,). ❑ Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sen sor(s). Model: ❑Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑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 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) : 0 System set-up Q Alarm history report Technician Name(print): Garrett Warren Signature: q4",eff y4vwoc Certification No 842126 License. No.: 588098 Testing Company Name:TAIT Environmental Services,Inc. Phone No.: 714560-8222 Testing Company Address:701 N Parkcenter Dr.,Santa Ana,CA,92705 Date of Testing/Seryicing: 5-26-2017