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ci 4. GFTTIFR-NYAN IN(. GR Job # 20-631623""U Appendix VI JUL 15 2015 MONITORING SYSTEM CERTIFICATION -Nw iR0!`\1 FNTA' For Use By All Jurisdictions Within the State of Califomia --a Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations 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 ownerloperator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. Generallnformabon Facility Name: Estes Express Bldg. No.. Site Address: 7611 S Airport Way City: Stockton zip: Facility Contact Person Contact Phone No.. Make/Model of Monitoring System: TLS -350 Date of TestinglServicing: 7/1/2015 B. Inventory of Equipment TestedlCertified Check the appropriate boxes to Indicate Tank ID: Diesel M In -Tank Gauging Probe. 0 Annular Space or Vault Sensor. M Piping Sump 1 Trench Sensor(s). ❑ Fill Sump Sensor(s). ❑ Mechanical Line Leak Detector. ❑ Electronic Line Leak Detector ❑ Tank Overfill! Nigh -Level Sensor. ❑ Other (specify equipment type and r Tank ID: ❑ In -Tank Gauging Probe. ❑ Annular Space or Vault Sensor. ❑ Piping Sump! Trench Sensor(s). ❑ Fill Sump Sensor(s). ❑ Mechanical Line Leak Detector ❑ Electronic Line Leak Detector ❑ Tank Overfill I High -Level Sensor. ❑ Other (specify equipment and n Dispenser ID: ❑ Dispenser Containment Sensor(s) E3 Shear VaNe(s). ❑ Dispenser Containment Fli and Dispenser ii ❑ Dispenser Containment Sensor(s). ❑ Shear Valve(s). ❑ Disoenser Containment Flnaflcl anri Dispenser [D: Model: MAG t Model: 744380.303 Model: 794380-206 Model: Model: Model: Modei in Section E on Pane 9) Model: Model Model: Model: Model: Model: Model: in Section E on Pane 21 Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s)- ❑ Dispenser Containment Floats and Chains . If the facility contains more tanks or dispensers, copy this form I Tank ID: ❑ In -Tank Gauging Probe ❑ Annular Space or Vault Sensor. ❑ Piping Sump I Trench Sensor(s). ❑ Fill Sump Sensor(s). ❑ Mechanical Line Leak Detector. ❑ Electronic Line Leak Detector ❑ Tank Overfill/ High -Level Sensor. ❑ Other (specify equipment type anc Tank ID: ❑ In -Tank Gauging Probe. ❑ Annular Space or Vault Sensor. ❑ Piping Sump I Trench Sensor(s). ❑ Fill Sump Sensor(s). ❑ Mechanical Line Leak Detector. ❑ Electronic Line Leak Detector ❑ Tank Overfill i High -Level Sensor. ❑ Other specify equipment type and Dispenser ID: ❑ Dispenser Containment Sensor(s) E3 Shear Vah+e(s). Dispenser 10: ❑ Dispenser Containment Sensor(s) ❑ Shear Valve(s), ❑ n;-—, _. Dispenser Ii ❑ Dispenser Containment Sensor(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floalrst ani for every tank and dispenser at the facility. Model: Model_ Model: Model: Model: Model: Model: in Sect Model: Model: Model: Model: Model: Model: Model: model In Sect Model: Chains . Model Chain(s), Model e. Certification - I certify that the equipment identified in this document was Inspectedlserviced in accordance with the manufacturers' guidelines. Attached to this Certification is Informatlon (e.g. manufacturers' checklists) necessary to verify 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 all that apply): ® System set-up ® Alarm history report Technician Name (print): .lose Carrasco Signature: r 31-v Certification No B35934 License. No. 220793 Testing Company Name: Gettler-R an Inc. Phone No.. 925-551-7555 Testing Company Address: 6805 Sierra Court Suite G, Dublin, Ca. 94568 Monitoring System Certification Page 1 of 4 Date of Testing/Servicing: 711/2015 12107