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®Gwmr-RYAN INC. GR Job#, 418200072 r Appendix VI r ' az Jent�taly 2006 MONITORING SYSTEM CERTIFICATION MAR 0 2 2018 For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7,Health and Safety Code; Chapter 16,Division 3, Title 23, California Code of Regulations ENVIHUlli��tiMtiv iiAL riciiLTH This form must be used to document testing and servicing of monitoring equipment.A separate certifica0on or report rnf>!�bd prepared Wfdr"T 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 6080 Bldg.No.: Site Address: 85 E. Louise Ave Cay: Lathrop Zip; 95330 Facility Contact Person: Daryl Lee Contact Phone No.: 415-902-5089 Make/Model of Monitoring System: TLS-350 Date of Testing/Servicing: 1/29/2018_ B. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicate specific equipment Ins serviced: Tank ID: 8 7 Tank ID: 91 i In-Tank Gauging Probe. Model: 54 7 3 9 0-1 1 1 ID In-Tank Gauging Probe. Model: 547390-111 Annular Space or Vault Sensor. Model: 794380-303m Annular Space or Vault Sensor. Model: 794380-303 i Piping Sump/Trench Sensor(s). Model: 79438 -208 0 m Piping Sump/Trench Sensor(s). Model: 7 94 3 8 0-2 0 8 i Fill Sump Sensor(s). Model: 794380-208 m Fill Sump Sensor(s). Model: 794380-208 Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: Electronic Line Leak Detector Model: 848480 m Electronic Line Leak Detector Model: 848480 Tank Overfill/High-Level Sensor. Model:yR m Tank Overfill/High-Level Sensor. Model: VR Other(specify equipment type and model in Section E on Page 2). ❑ Others ui ment 4W and model in Section E on Page 2). Tank ID: nST Tank ID: i In-Tank Gauging Probe. Model: S47390-111 ❑ In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model; 794380-303 ❑ Annular Space or Vault Sensor. Model: i Piping Sump/Trench Sensor(s). Model: - Cl Piping Sump/Trench Sensor(s). Model; Fill Sump Sensor(s). Model: 794380-208 ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: i Electronic Line Leak Detector Model: 848480 ❑ Electronic Line Leak Detector Model: 01 Tank Overfill/High-Level Sensor. Model: VR ❑ Tank Overfill/High-Level Sensor. Model: Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Pa e 2. Dispenser ID: 1/2 Dispenser ID: 3/4 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). ❑ Dispenser Containment Float(s) and Chain(s). Dispensar ID: 5/6 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 Float(s) and Chain(s). ❑ 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). ❑ 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 - 1 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 generati s�rts, 1 have also attached a copy of the report;(check all that apply): El system set-up 0 Alarm history port 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 Suite G.,Dublin CA 94568 Data of Testing/Servicing: 1/29/18 Monitoring System Certification Page 1 of 4 12107 1