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9255517888 Line 10 41:22 07-19-2012 215 li 6E7%FN-RYAN INC. GR Job# 20-581614 Appendix VI MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of CaMbinte 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 owner/operator.The ownertoperator must submit a copy of this forth to the local agency regulating UST systems within 30 days attest date. A. General Information Facllity Name: PG&E Bldg.No.: Site address: 4040 West Lane city, Stockton Zip: Facility Contact Person: Alex Contact Phone No.: Make/Model of Monitoring System: Veeder Root TLS 350 Date of Testing/Servidng: 6/28/2012 S. Inventory of Equipment TestedlCertified Check the appropriate boxes to indicatespecific equipment ins ectetliserviced: Tank ID: Unleaded Tank lD: ❑ In-Tank Gauging Probe. Model ❑ In-Tank Gauging Probe. Model ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model; M Piping Sump)Trench Ssnsor(s). Model: 54380-208 ❑ Piping Sump/Trench Salamis). Model: ❑ FIJI Sump Sensoria). Model: ❑ Fill Sump Sensor(s). Model: Et Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector Model: ❑ Electronic Line Lesk Detector Model: ❑ Tank Overfill/High-Level Sensor Model, ❑ Tank Overfill I Hlgh-Levet Sensor. Model: ❑ Other ispecifireoulomentVipe and model in Section E on Pa e 2. ❑ Other iispeciulpmsnt tyg2 and model in Section E on Pa e 2. Tank ID: Tank ID: ❑ Io-Tank Gauging Probe- Madel: ❑ In-Tank Gauging Probe. Mode): ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump r Trench Sensor(s). Model; ❑ FIII Sump Sensoria). Model: ❑ Fill Sump Sensor(s), Mlodel- ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Madel: ❑ Electronic Lim Leak Detector Model: ❑ Electronic Um Leak Detector Model: ❑ Tank Overfill)High-Level Sensor, Model: ❑ Tank Overall)High-Leve!Sensor. Model: ❑ Other(specify equipment and mode)In Section Eon Page 2. ❑ Other himcify e ul menC and model in Secdon E on Pae 2. DlspenserlD: — - Dispenser i d 2 Dispenser ID: Dispenser 3 8 4 ❑ Dispenser Containment Sansor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Disoenser Containment Floats)and Chaints) ❑ Dispenser Containment Floats and Chablis), Dispenser ID: Dispenser 5&6 Dispenser ID: Dispenser?&8 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chain s. ❑ Dispenser Containment Rawls)and Chain s. Dispenser ID: Dispenser 9&10 Dispenser ID: Dispenser 11&12 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(a). Model. ❑ Shear Valve(e). ❑ ShearVali ❑ Dispenser Containment Floats and Chains. ❑ Dispenser Containment Floats)and Chain(a 'It the facility contains more tanks or dispensers,copy this from.Include inronnation for every tank and dispenser at the facility. C. Certification - I certify that the equipment identified In this document was Inspectedfsar iced 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 Pian showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the report;Icheck all that apply): M System set-up W Alarm history report Technician Name(print): Mike Pratt Signature: Mike Pratt Certification No.: A29265 License.No.: 220793 Testing Company Name: Gettier-Ryan Inc. Phone No.: 925-551-7555 Testing Company Address: 6747 Sierra Court Suite J,Dublin,Ca.94568 Date of Testing)Serodrig: 6/2812012 Monitoring System Certification Page 1 of4 12107 1