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To:20948a3433@rctaxxoo Fax: +12094683433 9e 1 of 11 1010 812015 10:38 AM �q From:try;eFMall Gayer Fax:(714)578-2499 � ApperKUXVI (Copies ofMomtonngSystem Certifimtionfear,and UST Monitoring Plot Plan available athttp://w�tcarboaT1.s.Ca.g0V � )a MONITORING SYSTEM CERTIFICATION (V`E'V�® For Use By All Juaisdldf0W Withal the State of Calffomia Authority Cited Chapter 67,Health and Safety C0414 Chapter 16,Division 3,Tide 23,Ca6forniaCode ofRRepdations 6 . This foan must be used to document testing and servicing of monitoring equipment.A separate certification or report must be d The f cQOIS monitoring systern control panel by the techuidanwho performs file work Acopy of this form must be providedto the tank system ovmen'0pa'etor. ewnedopemtor must submit acopy mfthoform tothe local agency regulatingUST sy vMlin 30 days of test date. ENVIRONMENTAL A. General Informational-W nCOACMACA17 Facility Name: Pacific Gas and Electric Company Facility ID: PG Site Address: 4040 West Ln. City: Stockton Zip: 95220404 Facility Contact Person: Alex Steel Cc ri act Phone No.: Make/Model of Monitoring System: Veeder Root TLS-350 Date of Testing/Sery c ng: 2015-09 18 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: TsnklD: Tt:Unleaded Tank lD: T2:Diesel ❑ In-Tank Gauging Probe. Model:' -...�❑In-Tank Ganging Probe. W Q Annular Space or Vank Sensor. Model: 794390-420 Q Annular Space or Valk Sensor. ❑X Piping sump/Trendy Sensor(s). Model: 794380-208 Q Piping Sump/Trench Scnsor(s). ❑ Fik Sump SansOr(s). Model: ❑Fik Sump Selsor(s)❑ Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. QEledmnic Line Leak Detector. Model: Red Jacket ©Elechnic Lire Leak Ddector. Model: Red Jacket lDispmsff Overfill/I-Lgh-Level Sensor. Model: ❑TankOverBll/f5gh-Level Sensor. Model: r(speafy equipmenttype aid model n SectionE on Page 2) Other(s eafy eguipmet type and model in Section EE on Pa e: Waste Oil TankID: Hydrolic Fluid ank Gauging Probe. Model: ❑In-TankGauging Probe. Model: ular Space or Vault Sensor. Model: 794390-420 0 Annular Space or Vault Sensor. Madel: 794390-420 ng Smnp/Trend, - Model: 794380-208 ❑Piping Sump/Trench Sensors) Model: Sump Sensor($) Model: ❑Fin Sump Sansor(4 Model: hanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: d unic Line Leak Ddector. Model: ❑Electronic Line Leak Detector. Model: 794390-42(1 X Tank Overfill/I-figh-Level Sensor. Model: 794'9D-420 k Overfill/Fkgh-Level Sensor. Model: ❑er($panty equipment typeand model in Section E on Page 2) ❑Other(specify eguipmet type and model in SectionE on Page 2) psef ID: Unleaded 1-2 Dispenser ID: —Unleaded 3-4 QDispemer Containment Seneor(s). Model: 794380-208 Q Dispense'Contaimnent Senson(s). Model: 794380-208 QShear Valve($). 0 Shear Valve(,). ❑ Dispenser Containment Heat($)and Ch"(')- — I❑_Dispense Contaianent Float(s)and Chain(s). Dispenser ID: Waste Oil Disperser ID: X❑ Dispense'Comivanlem Sena01[$). Model: 794380-208 ❑Dispense Containment Sensor(s). Model: QSheer Valy KI). ❑Shear Valve($). ❑ Dispenser Containmem Float(s)and Chain(s). ❑Dispense Containmem Float(s)and Cha.n(s)_._-.y _�T._� *If the faality ordains moretanks or dispersos,mpy dis form Indude irfarnution forovery tank and dispense'ct the faciRty.- C. Certiication-I certify that the equipment identified it the document was inspected/serviced in accordance with the manufacturer s' guideines.Attached to this Certification is information(eg.manufacturers'chechists)necessary to verify that this inforrmtim s correct and a plot pian 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 Z Alarm history report Tednhician Name(print) Vidor Guerrero 'swot �LilPmew Signature: Certification No.: 836532 License.No.: 588098 Testing Company Name: TAIT ENVIRONMENTAL SERVICES phone No.: 714560-8222 Testing Company Address: unsorrm tW,,,MrjFAWjflagCA971D6 Date of Testing/Servicing: 2015-09-18