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Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://Nvww.waterboards.ca.gov.) MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Withbr the State of California Authority Cited:Cis apter 6.7,Health and Safety Code,Chapter 16,Division 3, Title 23,California Code of Regulations This form must be used to document testing and servicing of monitoring equipment.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 owner/operator 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: Pacific Gas and Electric Company Facility ID: PGE095 Site Address: 4040 West Ln. Cit,: Stockton Zip: 95204 Facilitv 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: Motor Oil AST Tank ID: Hydraulic Oil AST ❑ In-Tank Gaugi ng Probe. Model ❑In-TankGauging Probe. Model: ❑X Annular Space or Vault Sensor. Model: 794390-420 Annular Space or Vault Sensor. Model: 794390-420 '❑ 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: ❑ Tank Overfill/High-Level Sensor. Model: Q Tank Overfill/High-Level Sensor. Model: 794390-420 ❑ Other(specify equipment type and model in Section E on Page 2). ❑Other(specify equipment type and model it Section E on Page 2). Tank ID: Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ In-TankGauging 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: I❑ Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ❑ Electronic Lite 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 Vatve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: ❑ Shear Vabe(,). ❑Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). 'If the facility curtains more tanks or dispensers,copy this form. Include informatim for every tank and diyrenser at the fncilit}. C. Certification-I certify that the equipment identified in this document was inspected/serviced in accordance Hith the manufacturers' guidelines.Attached to this Certification is information(e.g.manufacturers' checklists)necessary to verih that this information is correct and a Plot Plan showing the layout of monitoring equipment.For a ny equipment capable of generating such reports,1 have also attached a copy of the report;(check alithatapply) : N System set-up ❑X Alarm history report Technician Name(print): Pat Banbury Signature: Pat Eaouuy Certification No A20465 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: 9/20/2018