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RECEAVLU OCT 01 2018 Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at littp://wwtiv.waterboards.ca.gov.) ENVIRONMENTAL HEALTH MONITORING SYSTEM CERTIFICATION . P9PO `�T��rNT For Use By All Jurisdictions[Vithin the State of California y rte[: rapter 6.7,Health and Safety Code,Chapter 16,Division 3, Title 23,California Code ofRegulations This form must be used to docwnertt testing and servicing of monitoring eq uipment.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. The mvner/operator must submit a copy o fthis 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 Zip: 95204 Facility Contact Person: Alex Steele Contact Phone No.: (916)439-3477 Make/Model of Monitoring System: Veeder Root TLS-350 Date of Testing/Servicing: 9/20/2018 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: Unleaded Tank ID: Diesel ❑ g g 2650960200 0 In-TankGauging Probe. Model: 847390-107 X In-Tank Gau in Probe. Model: 0 Annular Space or Vault Sensor. Model: 794390-420 0 Annular Space or Vault Sensor. Model: 794390-420 0 Piping Sump/Trench Sensor(s). Model: 794380-208 0 Piping Sump/Trench Sensor(s). Model: 794380-208 ❑ Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: PLLD Electronic Lune Leak Detector. Model: PLLD ❑ Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill/High-Level Sensor. Model: 0 Other(specify equipment type and model in Section E on Page 2). x❑Other(specify equipment type and model in Section E on Page 2). Tank ID: Waste Oil Tank ID: ❑ In-Tank Gauging Probe. Model: ❑In=lankGauging Probe. Model: ❑X Annular Space or Vault Sensor. Model: 794390-420 ❑Annular Space or Vault Sensor. Model: 0 Piping Sump/Trench Sensor(s). Model: 794380-208 ❑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 L une Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑X Tank Overfill/High-Level Sensor. Model: 794390-420 ❑Tank Overfill/High-Level Sensor. Model: 0 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: Diesel 1-2 0 Dispenser Containment Sensor(s). Model: 794380-208 0 Dispenser Containment Sensor(s). Model: 794380-208 0 Shear Valve(s). 0 Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: Unleaded 3-4 Dispenser ID: ❑X Dispenser Contauunent Sensor(s). Model: 794380-208 ❑Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). ❑Shear Vatve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). *1f the facility contains more tanks or dispensers,copy this form.include information forevery 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 informations 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 nll thnt app/y) : 0 System set-up 0 Alarm history report Technician Name(print): Pat Banbury Signature: pat 6"&VIy Certification No A20465 License. No.: 588098 Testing Company Name:TAIT Environmental Services,Inc. Phone No.: 7t4560-8222 Testing Company Address:701 N Parkcenter Dr.,Santa Ana,CA,92705 Date of Testing/Servicing: 9/20/2018