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®GETTLER-RYAN INC. • O Job # 20-572367 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, Tide 23, California Code of Regulations This forth 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: PG&E Stockton Service Center Bldg.No.: She Address: 4040 West Lane city. Stockton zip: Facility Contact Person: Contact Phone No.: MakelModel of Monitonng System: Veeder-Root TLS 350 Date of Testing/Servicing: 9127/2011 B. Inventory of Equipment Test"Certified Check the appropriate boxes to Indicatespecific equipment Inspected/serviced: Tank to: Unleaded Tank ID: Diesel ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: CO Annular Space or Vault Sensor. Model: 794380420 12 Annular Space or Vault Sensor. Model: 794380-420 D Piping Sump/Trench Sensor(s). Model: 794380.208 © Piping Sump/Trench Sensors). Model: 794380-208 ❑ 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: 848480 © Electronic Line Leak Detector Model: 848480 ❑ 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 Ispecify equieMnt type and model in Section E on Pae 2. Tank to: Waste-oil Tank ID: ❑ In-Tank Gauging Probe. Model ❑ In-Tank Gauging Probe. Model © Annular Space or Vault Sensor. Model: 794380420 ❑ Annular Space or Vault Sensor. Model: 0 Piping Sump/Trench Sensor(s). Model: 794380.208 ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensons). Madel: ❑ 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: 794380420 ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify ui ment type and model In Section E on Page 2). ❑ Other(specify equipment and model in Section E on Page 21. Dispenser 1D: 1 DlspenserlD: 2 IM Dispenser Containment Sensof(s). Model: 794380-208 © Dispenser Containment Sensor(s). Model: 794380.208 © Shear Valve(s). © Shear Valve(s). ❑ Dispenser Containment Eta s and Chains. ❑ Dispenser Contammem Floa s and Chains. Dispenser to: 1/2 Dispenser 10: © Dispenser Containment Sensor(s). Model: 794380.208 ❑ Dispenser Containment Sensw(s). Model: © Shear Valve(s). ❑ Shear VaNe(s). ❑ Dispenser Containment Float(s)and Chain(s). i ❑ Dispenser Containment Float(s)and Chain(s). Dispenser 10: Dispenser to: ❑ Dispenser Containment Sensof(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Vahre(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floags)and Chain(s) ❑ Dispenser Containment Floats 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/serviced 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): m System set-up © Alarm history report ' Technician Name(print): Chris San Nicolas Signature: /'%— Certification No.: B33787 License.No.: 220793 Testing Company Name: Gettler-Ryan Inc. PhoneNo.: 925-551-7555 Testing Company Address: 6747 Sierra Court Suite J, Dublin, Ca.94568 Date ofTestirg/Servicing: 9127/2011 Monitoring System Certification Page 1 of 4 12/07 1