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Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at httpR/www.waterboards.ca.gov .) MONITORING SYSTEM CERTIFICATION SEP 2 8 2017 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 of Regulations _ This form must be used to document testingand servicing of monitoring equipment.A s arate certification or report T �_TH g gseparate p � p��bti'pfep`azed for each ' monitoring system control panel by the technician who performs the work. A copy of this form must be provided to t0mk sy,L' awner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. �-'� ° JA, ' a A. General Information Facility Name: Pacific Gas and Electric Company Facility ID: PGE095 Site Address: 4040 West Ln. Cite: Stockton Zip: 95204 Facility Contact Person: Alex Steele Contact Phone No.: 209-736-6426 Make/Model of Monitoring System: Veeder-root TLS-350 Date of Testing/Servicing: 09/13/2017 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/seryiced: Tank ID: T1:Unleaded Tank ID: T2:Diesel 0 In-Tank Gauging Probe. Model: 847390-107 In-Tank Gauging Probe. Model: 847390-107 ❑ Annular Space or Vault Sensor. Model: 794390-420 Annular Space or Vault Sensor. Model: 794390-420 ❑ Piping Sump/Trench Sensor(s). Model: 794380-208 piping Sump/Trench Sensor(,). Model: 794380-208 ❑ Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: 0 ElectronicL Line Leak Detector. Model: Red Jacket Electronic Line Leak Detector. Model: Red Jacket ❑ Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment type and model in Sectio n k on Page 2) ❑Other(specify equipment type and model in Section E on Page 2). Tank ID: Waste Oil i' 41 Tank ID: Hydrolic Fluid ❑ In-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: QAnnular Space or Vault Sensor. Model: 794390-420 0 Annular Space or Vault Sensor. Model: 794390-420 * Piping Sump/Trench Sensor(s). Model: 794380-208 ❑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: — E]Electronic Line Leak Detector. Model: I❑X Tank Overfill/High-Level Sensor. Model 794390-420 R Tank Overfill/High-Level Sensor, Model: 794390-420 F] 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: Unleaded 1-2 Dispenser ID: Unleaded 3-4 Dispenser Containment Sensor(s). Model: 794380-208 ❑X Dispenser Containment Sensor(s). Model: 794380-208 0 Shear Valve(,). M Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: Diesel Dispenser ID: ZDispenser Containment Sensor(s). Model: 794380-208 ❑Dispenser Containment Sen sor(s). Model: QShear Valve(s). ❑Shear Valve(,). ❑ 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) : Q System set-up 0 Alarm history report Technician Name(print): Garrett Warren Signature: Cfazw&2f/azam Certification No B42126 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/Servicing: 09/13/2017