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9255517888 Line 1 • 14;10:02 10-12-2012 3/6 GETrLEa-RYAN INC. GRJob# 20-581987 Appendix VI MONITORING SYSTEM CERTIFICATION For Use By All Jurisdich'ons 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 control panel by the technician who performs the work.A copy of this form must be provided to the tank system ownerloperator.The owner/operator must submit a copy of this form to the local agency regulating DST systems within 30 days of test date. A. General Information Facility Name: PG&E Bldg.No.: She Address: 4040 West Lane City: Stockton Zip: Facility Contact Person: Alex Steele Contact Phone No.: 209.337-8902 Make/Mole)of Monitoring System: TLS 350 Date of Testing/Servldng: 9/28/2012 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment ins ctedlserviced: Tank ID: Waste Antifreeze Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: 794390.420 ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensogs). Mooed: ❑ Fill Sump Sensor(s). Madel: ❑ FIII Sump Sensoria). ModaC ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electron],Line Leak Detector Model: ow ❑ Electronic Line Leak Detector Model: ❑ Tank Overall I Hlgh-Level Sensor. Model: ❑ Tank Overall I High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Pace 2. ❑ Other(specify equipment type and model in Section E on Pane 2). TanklD: TanklD: ❑ in-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model; ❑ Piping Sump/Trench Sensoria). Model: ❑ Piping Sump/Trench Sensoria). Model: ❑ Fill Sump Senores). Model: ❑ FIII Sump Sensor(s). Model; ❑ Mechanical Line Leak Detector. Motlel: ❑ Mechanical Line Leak Detector. Madel: ❑ Electronic Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: ❑ Tank OveKll l High-!Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Madel; ❑ Others eci ui mend type and model in Section E on Pae 2). ❑ Other(specify equipment tvpe and rootlet in Section E on Page 2. DispenserID: Dispenser E3 Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Senscr(s). Model: ❑ Shear Valve(s). ❑ Shearhear Velve(s). ❑ Dispenser Containment Floats and Chain s. ❑ Dispenser Containment I'mit(s)and Cheln(s). Dispenser 10: Dispenser ID: ❑ Dispenser Containment Sensogs). Model: ❑ Dispenser Contalnment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chaln s. ❑ pis enser Containment Floats and Chain(s), Dispenser 10: DispenserlD: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dis nser Containment Floats E3 and Chains. Dis enser Containment Floe s anti Chains. •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 correct and a Plot Plan showing the layout of monitoring equipment For any equipment capable of generating such reports, f have also attached a copy of the report;(check all that apply): ® System set-up M Alarm history report Technician Name(pdn0: Wes Morrison Signature: Wes Morrison Certmcation No.: 838044 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 Testing/servicing: 9/2812012 Monitoring System Certification Page I of 4 12/07 1