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9255517A88 Une1 7 39a.m. 12-01-2009 3112 111V1\11 1\l7 01r71L' 111 LrJ1<11P1 11V11 For se By X11 Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code;Chapter 16, Division 3, Title 23, California Code ofRegtdations This fort must be used to document testing and servicing of monitoring equipment A separate certification or report must be Prepared for each mpnitorine 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 FacilityName: PG&E Bldg.No.: Site Address: 4040 West Lane City: Stockton zip; Facility Contact Person: Michelle Le Contact Phone No.: ( ) Make/Model of Monitoring System: TLS-350 Date of Testing/Servicing: 11/18/2009 B. Inventory of Equipment Tested/Cerfified Cheche appropriate boxes to indicate specific equipment iae ted/serviced: Tank1D: 87 Tank ID: Diesel ® In-Tank Gauging Probe. Model: 847390-109 Q In-Tank Gauging Probe. Model: 847390.109 ®Annular Space or Vault Sensor. Model: 794390-{20 ®Annular Space or Vault Sensor. Model: 794390420 ®Piping Sump/Trench Sensor(s). Model: 794380-203 ®Piping Sump/Trench Smsor(s). Modcl: 794380-208 Q Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: I Mechanical Line Leak Detector. Model: Q Mechanical Linc Leak Detector. Model: ®Electronic Line Leak Detector. Model: 8484 ®Electronic Line Leak Detector. Model: 8484 Q Tank Overfill/High-Level Sensor. Model: ❑Tank Ovefill/Highlevel Sensor. Model: ❑Other(specify equipment type and model in Section E on Page 2), ❑Other(specify equipment type and model in Section E on Page 2). Tank ID: Waste Oil TaakID: Lube ❑In-Tank Gauging Probe. Model: ❑In Gauging Probe. Model: ®Annular Spamor Vault Sensor. Model; 79439020 23 Annular Space or Vault Sensor. Madel: 79439020 ®Piping Sump/Trench Sensor(s). Model: 794380-208 13Piping Sump/Trench Sensor(s). Model: Q Fill Sump Sensor(s). Model: ❑Fill Sump Smsor(s). Modcl: Q Mechanical Line Leak Detector. Model: Q Mechanical Line Leak Detector. model" ❑Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ®Tank Overfill/High-Level Sensor. Model: 794390420 ®Tank Overfill/High-Level Sensor. Model: 794390.420 ❑Other(specify equipment type and model in Section E on Page 2). Q Other(specify equipment type and model in Section E on Page 2). Dispenser 1D: 1-Diesel Dispenser ID: 2-UL ®Dispenser Containment Sensor(s). Model: 794380-208 0 Dispenser Containment Sensor(s). Model: 784380-20g M Shear Valve($). ®Shear Valve($). ❑ Dispenser Containment Rawls)and Chain(s). Q Dispenser Containment Flon(s)and Chain(s). Dispenser ID: 3-UL Dispenser ID: ®Dispenses Containment Sensor(s). Model: 794380-208 ❑Dispenser Containment Sensor(s). Model: ®Shear Valve(s). ❑Shear Valve(s). ❑Dispenser Containment Flon(s)and Chain(s). ❑Dispenser Containment Floats)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenscr Containment Sensor(s). Model: Q Dispenser Containment Sensor(s). Model: ❑ShearValve(s). ❑Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Flow(s)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 verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equi ment capable of generating such reports,I have also attached a copy of the report;(check all that apply): ®System set-up ,N Alarm history report Technician Name(print): Joe Serna Signature: _✓ A �� Certification No.: A30455 License.No.:f 27079 Testing Company Name: Gettler-Ryan Inc. ✓Phone No.:(925) 5514777 Testing Company Address: 6747 Sierra Ct., Dublin, Ca Date of Testing/Servicing: 11/1812009 Page 1 of 3