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GfTTLER-RYAN INC. -,R Job#RECEN�_.D Appendix VI MONITORING SYSTEM CERTIFICATION JAN 3 1 2017 For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 96, Division 3, Title 23, California Code f Regulations ENVIRONMENTAL HULTH This form must be used to document testing and servicing of monitoring equipment.A separate certification oripb�t�mu t 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 2186 Bldg.No.: Site Address: 3212 N. California City: Stockton zip: Facility Contact Person Daryl Lee Contact Phone No.: 415-905-5089 Make/Model of Monitoring System. TLS350 Date of Testing/Servicing: 1/5/2017 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific eau iment inspected/serviced: FTa�nk ID: T1 Master Tank ID: T2 Siphon In-TankGauging Probe. Model: 847390-109 ® n•Tank Gauging Probe. Model 847390-109 Annular Space or Vault Sensor. Model. 794390-409 ® Annular Space or Vault Sensor.Piping Sump/Trench Sensors. Model:( ) Madel: 794380-208 ® Piping Sump/Trench Sensor(s). Model: 794380-208 Fill Sump Sensor(s). Model: 794380.208 ® Fill Sum Sensor(s)- 0 Mechanical Line Leak Detector. pModel: 794380-208 Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector Model: 8484-80 ❑ Electronic Line Leak Detector ® Tank Overfill/Hi h-Levet Sensor. Model ❑ 9 Model: VR ® Tank Overfill/High-Level Sensor. Model: VR Other(specify ui ment type and model in Section E on Pa e 2 ❑ Other(specify equipment a and model in Section E on Pa e 2). FTa�n ID: T3-911 Tank ID: In-Tank Gauging Probe. Model: 847390-109 ❑ In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 794390.41)9 ❑ Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: 794380-208 ❑ Piping Sump/Trench Sensor(s). MadelFill Sump 5ensor(s). Model. 794380-208 ❑ Fill Sump Sensor(s). ModeC Mechanical Line Leak Detector Model: ❑ Mechanical Line Leak Detector. U1 Electronic Line Leak Detector Model: 8484-80 ❑ Electronic Line Leak Detector Model: ® Tank Overfill/High-Level Sensor. Model: VR 13 Tank Overfill/Hi h-Level Sensor. Model: El Other s eci equipment a and model in Section E on Page 2). 13g Model: Other s ecify equipment a and model in Secton Dispenser ID: 112 Dispenser ID: 3/4 ® Dispenser Containment Sensor(s). Model 794380-323 IR Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ® Shear Valve(s). 794380-323 ❑ Dis enser Containment Floats and Chain(s). ❑ Dis enser Containment Floats and Chain(s). Dispenser ID: 5/6 Dispenser ID: 7/g ® Dispenser Containment Sensor(s) Model: 794380-323 ED Dispenser Containment Sensor(s). ® Shear Valve(s). Model 794380-323 ❑ ® Shear Valve(s). Dispenser Containment Floats and Chains. 13Dis enser Containment Floats and Chains. DispenserlD: Dispenser ID: ❑ Dispenser Containment Sensor(s) Model: ❑ Dispenser Containment Sensor(s). El Shear Valve(s). C3 Shear Valve(s). Model: ❑ Dis enser Containment Floats and Chain(s). ❑ Dis enser 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 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 all that apply): p System set-up 0 Alarm history report Technician Name(print): Tim Adams Signature: Certification No.: B37367 License.No.: 220793 Testing Company Name: Gettler-Ryan Inc. Phone No.: 925-551-7555 Testing Company Address: 6805 Sierra Court Suite G, Dublin, Ca. 94568 Date of Testing/Servicing: 1/5/2017 Monitoring System Certification Page 1 of 4 12107 1