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PGE095 <br /> UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM ( Page 1 of 6) <br /> This form must be used to document testing and servicing of underground storage tank (UST) monitoring equipment. A copy <br /> of this form must be provided to the UST owner or operator. The owner or operator must submit a copy of this form to the local <br /> agency regulating the USTs within 30 days of the date of the monitoring system certification . <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Monitoring System Certification <br /> 10148345 09/18/2020 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) Building # <br /> Pacific Gas and Electric Company <br /> Business Site Address City ZIP Code <br /> 4040 West Ln . Stockton 95204 <br /> ll . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone # <br /> TAIT Environmental Services , Inc. (714) 560-8222 <br /> Mailing Address <br /> 11280 Trade Center Dr. , Rancho Cordova , CA 95742 <br /> Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification) <br /> Craig Feezell <br /> Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 588098 8374133 07-03-2021 <br /> Monitoring System Training and Certifications List all applicable certificationsj Expiration Date <br /> Veeder Root - A23508 06- 13-2021 <br /> III . RESULTS OF TESTING / SERVICING <br /> Indicate and attach the following reports if the monitoring equipment is capable of generating either. Y N NA <br /> 0 Monitoring System Set-up Alarm History Report <br /> Was any monitoring equipment replaced ? <br /> (If "Yes, " identify the specific devices replaced and list the manufacturer and model for all replacement parts in section IV below.) <br /> Was damage , debris , or liquid found inside any secondary containment systems? <br /> (If "Yes, " describe what was found in section IV below.) El 0 1 El <br /> Is all monitoring equipment operational per manufacturer's specifications ? <br /> (If "No, " describe why in section IV below.) <br /> IV. COMMENTS <br /> If directed to use this section, describe how and when the issues were or will be corrected. <br /> RECEIVED <br /> S E ° 2 2 2020 <br /> 'ENVIRONMENTAL HEALTH <br /> D;EPARTTI /1E 1`. T <br /> V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> I hereby certify that the equipment identified in this document was inspected/serviced in accordance with California Code of <br /> Regulations , Title 23 , Division 3 , Chapter 16, Section 2638 and all information contained herein is true and accurate. Attached to <br /> this certification is information (e. g . , manufacturers' checklists , monitoring system set-up , alarm history report, etc .) necessary <br /> to verify that this information and the site plan showing the layout of UST system is complete and accurate . <br /> UST Service Technician Signature <br /> *1' [:] Check If Action Item (s) Are Present <br /> CERS = California Environmental Reporting System, ID = Identification, [CC = International Code Council, Y = Yes, N = No, NA = Not Applicable <br />