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From:Wendell Gayer Fax:(714)576.2499 To:2094683433@rcfax.con Fax: +12094683433 Page 1 of 12 09,28!2016 9:11 AM Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at JIECEIVED MONITORING SYSTEM CERTIFICATION SEP 2 8 2016 For Use By All Jurisdictions Wither the State ofCaltfornia Axthoray Cited:Chapter 6.7,Health and Safety Code,Chapter 16,Di+rsion 3,Tale 23,California Code ofRegrrlatfons N� This form mustbe usedto document testing and servicing ofmonitoring equipment.Aseparate certification orreport must be Rrepareed�fo each monitoring system control panel by the technician who performs flee work. A copy of this form must be provided to h oHETH owner/operator must submit a copy ofthis form to the local agency regulating UST systems within 30 days of test date. DEPARTMENT A. General Information Facility Name: Pacific Gas and Electric Company Facility ID: PGE095 Site Address: 4040 West Ln. City: Stockton Zip: 95204 Facility Contact Person: Alex Steele Contact Phone No.: 209-337-8902 Make/Ivlodel of Monitcring System: Veeder-Root TLS-350 Date of Testing/Servicing: 9-12-2016 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment i nsp ected/serviced: Tank ID: T1:Unleaded � ^ 1TankID: yT2:Diesel In-Tank G Probe. Model: ❑In-Tank Gauging Probe. Model: _ ©Annular Space or Vault Sensor. Model: 794390-420 Armular Space or Vault Sensor. Model: 794390-420 ©Piping Sump/Trench Sensor(s). Model: 794380-208 ©Piping Sump/Trench Sensor(s). Model: 794380-208 i ❑ Fill Sump Sensor(s). Model: E]Fill Sump Sensor(.). Model: i ❑ Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ID Electronic Line Leak Detector. Model: Red Jacket 0 Electronic Line Leak Detector. Model: Red Jacket ❑Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill/High-Level Sensor. Model: _ ❑Other(specify equipment type ark model in Section E on Page 2). ❑Other(specify equipment t and model in Section E on Page 2). r�,� ramra � Tank ID: Waste Oil mIpr� I Tank ID: HydrolicFluid I ❑In-Tank Gauging Probe. Model: I❑In Tank Gauging Probe. Model: Annular Space or Vault Sensor, Model: 794390-420 ®Annular Space or Vault Sensor. Model: 794390-420 Piping Sump/Trench Sensor(.). Model: 794380-208 ❑Piping Sump/Trench Sensor(s). Model: ❑ Fill Stamp Sensor(s). Model: ❑Fin Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: 0 Tank Overfill/High-Level Sensor. Model: 794390-420 0 Tank Overfill/High-Level Sensor. Model: 794390-420 ❑Other(specify equipment type and model in Section E on Page 2). ❑Other(specify equipment type and model in Section E on Page 2). Dispenser ID: Unleaded 1-2 - Dispenser ID: Unleaded 3-4 ww- ..... - QDispenser Containmen t Sensor(s). Model: 794380 208 ©Dispenser Containment Sensor(s). Model: 794380.208 ® Shear Valve(.). ©Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(.). ❑Dispenser Containment Float(s)and Chain(s). DispenserED:�Diesel��~-_._..._.._...,.._.__._....__..._..,___............_._._..__....Ww.._.__.:_...._.....— DispenservID��--�_...._. ._._....._____.._._,.�._.__...._.__...._.._._._ _ - ❑X Dispenser Containment Sensor(s). Model: 794380-208 ❑Dispenser Containment Sensor(,). Model: ® Shear Valve(s). ❑Shear Va1ve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). *If the facility c ortains more tanks or dispensers,copy the fond.Induce infamaticn for everytank 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'check6sts)necessary to verify that this informations correctand a Pbt Plan showing the layout of monitoring equipment.For arty equipment capable of generating such reports,I have also attached a copy of the report;(check all that apply) : QSystem set-up ❑x Alarm history report Technician Name(print): Garrett Warren WCC ICvL Signature: Certification No.: B42126 License.No.: 588098 Testing Company Name: TAIT ENVIRONMENTAL SERVICES Phone No.: 714-560-8222 Testing Company Address: zi 3c soursDupoNT nuw,AN IMKCA92806 Date of Testing/Seryicing: 9-12-2016