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GfTrLER-RYAN INC. GR Job# 20-643301 Appendix VI MONITORING SYSTEM CERTIFICATION 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 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 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 Facility Name: Arco SS 2076 Bldg.No.: Site Address: 800 E. Kettleman Lane City: Lodi zip: Facility Contact Person: Daryl Lee Contact Phone No.: 415-902-5089 Make/Model of Monitoring System: TLS 35OR Date of Testing/Servicing: 12/15/2016 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicatespecific equipment Inspected/serviced: Tank ID: 87-1 Tank ID: 87.2 ® In-Tank Gauging Probe. Model: 846380-107 Ed In-Tank Gauging Probe. Model: 846380-107 ® Annular Space or Vault Sensor. Model: 794390-409 © Annular Space or Vault Sensor. Model: 794390-409 Q Piping Sump/Trench Sensor(s). Model: 794380-208 ® Piping Sump/Trench Sensor(s). Model: 794380-208 © Fill Sump Sensor(s). Model: 794380-208 © Fill Sump Sensor(s). Model: 794380-208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector Model: 8484.80 ❑ Electronic Line Leak Detector Model: ® Tank Overfill/High-Level Sensor. Model: VR ® Tank Overfill/High-Level Sensor. Model: VR ❑ Other(specify equipment and model in Section E on Pa e 2. ❑ Other(specify equipment a and model in Section E on Page 2). Tank ID: 87-3 Tank ID: 91 ® In-Tank Gauging Probe. Model: 846380-107 ® In-Tank Gauging Probe. Model: 846380-107 ® Annular Space or Vault Sensor. Model: 794390-409 10 Annular Space or Vault Sensor. Model: 794380-409 Cxi Piping Sump/Trench Sensor(s). Model: 794380-208 ® Piping Sump/Trench Sensor(s). Model: 794380-208 13 Fill Sump Sensor(s). Model: 794380-208 ® Fill Sump Sensor(s). Model: 794380-208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector Model: © Electronic Line Leak Detector Model: 8484.80 ® Tank Overfill/High-Level Sensor. Model: VR © Tank Overfill/High-Levet Sensor. Model: VR ❑ Other(specify equipment a and model in Section E on Page 2). ❑ Other(specify equipment a and model in Section E on Pa e 2. Dispenser ID: 1/2 Dispenser ID: 314 ® Dispenser Containment Sensor(s). Model: 794380-208 10 Dispenser Containment Sensor(s). Model: 794380-208 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: 516 Dispenser ID: 7/8 ® Dispenser Containment Sensor(s). Model: 794380-208 ® Dispenser Containment Sensor(s). Model: 794380-208 © Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dis enser Containment Floats and Chain(s), Dispenser ID: DispenserlD: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats 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 equipment capable of generating such reports, I have also attached a copy of the report;(check all that apply): ® System set-up fel Alarm history report Technician Name(print): David Rouse Signature: " '--- Certification No.: B44848 License.No.: 220793 Testing Company Name: Gettler-Ryan Inc. Phone No.: 925-551-7555 Testing Company Address: 6805 Sierra Court#G, Dublin,CA 94568 E VE 15/2016 MCEL, Monitoring System Certification Page 1 of 4 ' 12107 MAR 0 7 2017 ENVIRONMENTAL HEALTH DEPARTMENT 1