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NOV-19-2010 01 :23 PM GETTLER-RYAN INC. 9251 4770 P. 02
<br /> MONITORING SYSTEM CERTIFICATION
<br /> For Use Nr All.hu'is'dictinnr Within the,Pari,u1'Crrlilorrtin
<br /> Authority Cited: ChgptcrA_'. HiftilthMid St{ft:n ('ode: Chari"). 16, I)iltwim. 3e VA,2,7CWHiji-niaC'odrol'lfo)ralntinrrr
<br /> [his Form must be used to document testing and %erv+cinp of monitoring equipownt. Z,Syyg�(Ey tication pr recon n+u,Fj,- p p ,-[ y
<br /> unint�0u system,untml oauy;l by(lie technidart who performs the work, A copy ofthi.!arm most be provided in for+unk system own anperamr.
<br /> I'he orsnerroperntnr must submit a copy of this faro)it,the local agency regulnring I.K I':systems e•shin 3;I days of test dab.
<br /> A. General Information
<br /> F,wil,ly'Name: PG&E __ Iildg. Nu.:_
<br /> t itY+te Address: 4040 West Lann _ - C' 5to_cklon-----
<br /> Fucilq Contact Person! Alex Slee!o~ _ ('onlact I'honc Na.: 200 337-8902
<br /> hAaku Nalel of Monitoring 9wlrm; TL6 3f.D _ __ Dalt:W' fcming(Serv,cing' Yi0g120)0_.^.T
<br /> B. Inventory of Equipment Testctf/Certified
<br /> Check the approortatc baser b.iadicaM specific equipment Inspected/serviced:
<br /> Tank ID: un"ean 'rank ID: co,m
<br /> ❑In-lank[iauging Prolx. Nlu.kl: ❑in=1';mk f brngmg i'rt•M Mold: _,..W�...r
<br /> [�Annidor Space or Vault Series htodd: f14390 420 ❑e Annular Space or Vauh.Ncns.n :11,vlcl: •l94390.420F
<br /> U Pip mg Sump t'I'mnch SonAmt). \fodra: F943M.M0 S Piping Sump I'romch Smsoom Model: 741380-M8
<br /> ❑I'dl Sump Neftwim Modell: ❑1111 Sump 1rnw,nM Ni"&h
<br /> ❑Mechanical Linn I sok Detector. \1.det: — ❑Merhumud I,nc I ark Det iot. Modish _
<br /> (•�L kvnonlc Lin.Lusk udtedtur. \1..tlul 04114 Ell.kuuamcI me Icuk lessee. Model. 114+ •�-�
<br /> ❑ tart Usmlill i High-I.evel Sm.nr. ku,del. ❑'I nnL Ue crllll•thgh-I reel Smw. Mold:
<br /> ❑filler 6twi y eguipmeto lypw and model in.swuon F.nn Pass'_,. ❑0ther iatuxil%uptipuscnr i pc mrd model in Sectinn Fon Page 2). —_
<br /> Tank In, waatn oa 'rank ID',
<br /> ❑In.1:14k Gauging Probe. \1:..1,16. ❑In-l ane t iam;o)g Pribi, Model:
<br /> 1.3 Annular Sra,,ur Vault sense". 11...1-1 7e4.1no-sn ❑Annulm Spat,: it Vault Sensor. Model:
<br /> Q Pipes;Stamp I Tmneh Sdnsrv(s), N!..ddr 7!"1110-209 ❑PIl11nY tir1Oq. Irl:nCll\(]INOr.y \LHlcl:
<br /> ❑Fd!sump Senn..%1. Model. ❑I+ill Sump N,-ny,rls! Mtdwl
<br /> ❑11k.1,antcal Line Leak Darn:bn Modcl. 11 Mcrhamcal l me Leak Ihga+.n Mndrl
<br /> ❑PI[avnmr:Lena Leek D,4c i u Model. �- ❑1.luunm,c 1 ,to Lok Poseur, Nhstel'.
<br /> a
<br /> lank(earful r High l V cl yemsor. Mnda1 7%43!MA2e ❑ 1 unk(her ill r High-Ix,ul Sdwtu. Model
<br /> ❑Other(specily equipment type 44d.m.rdei in Section F on Page_`). ❑Orhel(Sts:.I,rtptiprrumr type net unrdel in Section 1.nn Page 2)_
<br /> Dispenserft): dr llnyened Dispenser ID' #2 uNmnen
<br /> [ii f.)itp[mdr Canminmum Ssmstal%1. NJ...let: 794390206 ❑e Dkjwn,,TI anaintmvl NenynnJl. Ntosivl 794990.209
<br /> d Sheen Va!vdl%). �• l]Shia
<br /> ❑Dis)mnwr Conminmwm Floaunl unit ChainLa). ❑Dispense t.'nuimncnt I iuuau)and(`hulnt%1
<br /> Dispenser l D: I)kw 1,2 _ Dispenser 11)•
<br /> Q Diry.orwv(',ntainmeru Senson4). Motais 7943F.0 20A ❑Disliens,r(.•uminmono Nene r0I Mild&
<br /> I].Shce,r Vaho(9) ❑Shan Van',hl.
<br /> ❑Dispenser("on+ainmem Roads)and Chon(s). ❑Dispcaser('o11ti nmp t llh,au.+1 nd(hain([).
<br /> Irw�tr��
<br /> Dispenser ID: Dispenser 11k'
<br /> ❑nispertrr Containment Sens.nsl. NLriel: ❑t0inpen;er(bnt4tnlmnr\ens.ctrl Model: .^
<br /> ❑Shur Vah1:(sl L Slicer\'uhds).
<br /> ❑Dispcnter('ontainment Metal,)and['huinis) ❑Uisperr.V.l'ulllatmnc I.I loaf(st and Chuimsl.
<br /> �.
<br /> -If the facility contains more lanks nr dispensers.copy this Iiim. Include information for even•took and.h:ipcoser of The facility
<br /> C. Certification -I eerdiv that the equipmeut identified In this document was inspertcrVnrvlced in accordance with the maaaMetureri
<br /> Guidelines. Attached to this ('erNneatlou Is Information deg, Manufacturers' check!iets) Iw`reanary to verify that this Information i9
<br /> correct and a Plot Plan showing the layout of mnnitori ig equipment. For any r,I r�meot capable of geueratind such reports.1 hast also
<br /> attached a of the re ort:(a'he.,A afl dial appfyl: Svstem set-up U Algrm history report
<br /> .OPS' P sows r'yxn rw+�.,sere",.
<br /> tar.vnnygn 6prwe.o.m
<br /> .r!an N3mC(pant): Signature:, r'' 1 t xxrt=r..m.6vr•nm mm,vL3
<br /> 'PednllJCananse _-- .— - —�^"'�""„"'��y'�•.•_.-
<br /> ...__..._.._...--.. (.icamsr, tic:
<br /> ('cn*MniionNo.: 895934 --
<br /> No .5 551 7555
<br /> Phone .:f.92
<br /> 1 csri'1p Company Name: worn neon int. —_ .— — 11,091201P
<br /> \C:\mgk'UAn`1Uny Address. al4T5nnaC.oart_Oublin,C7e ..___ ___.,,.__�.
<br /> Pate of I'es11n crvromg' ._,_„^_•_—....
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