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F 6[TT1ER-RYAN INc. LAK Job # 0-631623 Appendix Vl A G E I L MONITORING SYSTEM CERTIFICATION AUG 2 g 2015 For Use By All Jurisdictions Within the State of Califomia Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California CMIRONMENTAL. Regulations a .4 r-,r,AnTg11l7j r This form 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 cwnerloperator. 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: Estes Bldg. No SiteAddress: 7611 S Airport city: Stockton Zip: Facility Contact Person: Contact Phone No Make/Model of Monitoring System: TLS 350 Date of TestinglServicing 3/20/2015 B. Inventory of Equipment Tested/Certified Check the aeproprlate boxes to indicate specific nuipment Iris ectedfserviced: Tank ID: 1 Tank ID: D in -Tank Gauging Probe. Model. MAG 13 In -Tank Gauging Probe. Model: Cx3 Annular Space or Vault Sensor. Model: 303 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump /Trench Sensogs). Model: 794380-208 ❑ Piping Sump I Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ MechanicaS Line Leak Detector, Model: ❑ Electronic Line Leak Detector Moder ❑ Electronic Line Leak Detector Model: ❑ Tank Overfill 1 High -Level Sensor. Model: 0 Tank Overfill l Nigh -Level Sensor. Model: ❑ Other (spectfy, equipment type and model in Section E on Page 2). Other (specify equipment and model in Section E on Page 2 Tank ID: Tank ID: ❑ to -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump 1 Trench Sensor(s). Model: 13 Piping Sump 1 Trench Sensor(s) Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s), Model: 11 Mechanical Line Leak Detector. Motlel: ❑ Mechanical Line Leak Detector. Model. ❑ Electronic Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: ❑ Tank Overfill! High-level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment a and model in Section E on Page 2 ❑ Others i equipment type and model in Section E on Page 2). Dispan aarIIll DlspenserlD: ❑ Dispenser Containment Sensor(s), Model: ❑ Dispenser Containment Sensor(s). Model ❑ Shear valve{$). ❑ Shear Valve($) ❑ Dis nser Containment Floats and Chain(s)- 7943BO-304 ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dis enser Containment Floats and Chains . DispenserlD: Dispenser to: C3 Dispenser Containment Sensor(s) Model: ❑ Dispenser Containment Sensor(s), Model: ❑ Shear Valve(s) ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chains . ❑ Dis enser Containment Floats and Chains _ 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 inspectedlserviced 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 ail that apply): ® System set-up ❑ Alarm history report Technician Name (print: Wes Morrison Signature Cerlification No.. B38044 License. No.. 220793 Testing Company Name: Gettler-Ryan Inc. Phone No 925-551-7555 Testing Company Address: 6805 Sierra Court Suite G Dublin, CA Date of TestinglServicing 8/20/2015 Monitoring Syatem Certification Page 1 of 4 12/07