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9255517888 Line I • 14:C9:24 10-12-2012 2/6 4 . 6errL n-RYA rr I c. GR Job# 20-581987 Appendix VI MONITORING SYSTEM CERTIFICATION 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 testing and servicing of monitoring equipment.A separate certification or report must be prepared for each monitoring system controf panel by the technician who performs the work.A copy of this form must be provided to the tank system owner/operator.The ownerloperator must submit a ropy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: PG&E Bldg.No.: Site Address: 4040 West Lane City: Stockton zip: Facility Contact Person: Alex Steele Contact Phone No.: 209-337-8902 MakerModel of Monitoring System: TLS 350 Date of TestingrServicing: 912812012 B. Inventory of Equipment Testod/Certified Check thea ro riate boxes to Indicatespecific equipment ins eted/serviced: Tank ID: I.Diesel Tank ID: Gas --' M Io-Tank Gauging Probe. Model: MAGI M In-Tank Gauging Probe. Model: MAGI ® Annular Space or Vault Sensor. Model: 794390-420 12 Annular Space or Vault Sensor. Model!79-419 .43 20 ® Piping Sump I Trench Sensor(s). Model: 794380-208 © Piping Sump/Trench Sensor(s). Model: 794380.208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Machankaf Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: 10 Electronic Line Leak Detector Model: 8448 © Electronic Line Leak Detector Model; 8448 ❑ Tank Overfill/HigMLevei Sensor. Model: ❑ Tank Overfill/High-Level Sensor Model: ❑ Other(specify equipment a and model in Section E on Pae 2. ❑ Other�apecify equiprnellmtEd model in Section E on Pae 21. Tank ID: Waste 011 Tank ID: Antifreeze ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 794390420 W Annular Space or Vauh Sensor. Model: 743— g�0-420-- ® Piping Sump/Trench Sensor(s). Motlel: 79438 -Z0� ❑ Piping Sump I Trench Sensor(s). Model: ❑ Fill Sump Sansor(s). Model: ❑ Fill Sump Senscr(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: 13 Tank Overfill/Hlgh-Level Sari model: 794 0 ❑ Tank Overfill I High-Level Sensor. Model: ❑ Others Equipment a and model In Section E on Pae 2). ❑ Others ui eM a and model in Sectio E on P e 2. DtspenserlD: Dispenser 1&2 Dispenser ID: Dispenser 3&4 IM Dispenser Containment Sensor(s). Model: 794381 © Dispenser Containment Sensor(s). Model, 794380.208 ® Sheer Valve(s). SI Shear Valve(s). ❑ DsipenserContainmer,LELOats antl Chains. ❑ Dis enser Containmerd Floats and Chain s. DlspenseriD: Dispenser 5&6 Dispenser ID: ® Dispenser Containment Sensors). Model: 794380.208 ❑ Dispenser Containment Sensor(s), Model: 51 ShearVaNe(s), ❑ ShearValve(s). ❑ Dispenser Containment Float s and Chain(s). ❑ Dispenser Containment Floats and Chain(s). Dkpe Dis ID: D ispenser 1D: ❑ Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model' ❑ shearvalve(s). ShearValve(s). ❑ Dispenser Containment Floats and Chains. Dispenser Containment Flcat(a)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/servioad in accordance with the manufacturers' guidelines. Attached to this Certification is Information (e.g. manufacturers' checklists) necessary to verity that this Information Is correct and 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): p System set-up IM Alarm history report Technician Name(print): Wes Morrison Signature: Was Morrison Cettitica8W No.: 638044 License,No.: 220793 Testing Company Name: Gettler-Ryan Inc. Phone No.: 925-551-7555 Testing Company Address: 6747 Sierra Court Suite J,Dublin,Ca.94568 Date of Test ng/Serviring: 9/28/2012 Monitoring System Certification Pagel of 12/07 1