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®1 GET TLER-RYAN INC. GR Job # � -6 Appendix Vl MONITORING SYSTEM CERTIFICATION MAR 2 7 2015 For Use By All Jurisdictions Within the State of CaliforniaA I I R0 I�,,x _JT Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, Cal'$�F, Code of �r�- 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 6080 Bldg.No.: Site Address: 85 E Louise Ave City: Lathrop zip: Facility Contact Person: Sarah Samuels Contact Phone No.. 360-371-8111 Make/Model of Monitoring System: VR TLS 35OR Date of Testing/Servicing: 3/20/2015 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment Inspected/serviced: Tank ID: 1-87 Tank ID: 2-91 ❑ in-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: © Annular Space or Vault Sensor. Model: 794390-303 © Annular Space or Vault Sensor, Model: 794390-303 © Piping Sump/Trench Sensor(s). Model: 794380-208 Q 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: O Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfili/High-Level Sensor. Model: ❑ Other(specify equipment a and model in Section E on Page 2). ❑ Other(specify equipment a and model in Section E on Pae 2). Tank ID: 3-Diesel Tank ID: ❑ In-Tank Gauging Probe. Model. ❑ In-Tank Gauging Probe. Model: © Annular Space or Vault Sensor. Model: 794390-303 ❑ Annular Space or Vault Sensor. Model: M Piping Sump/Trench Sensor(s), Model: 794380-208 O Piping Sump/Trench Sensor(s). Model: 10 Fill Sump Sensor(s). Model. 794380-208 ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: 13 Tank Overfill/High-Level Sensor. Model: O Tank Overfiii/High-Level Sensor. Model: ❑ Other(specify equipment a and model in Section E on Pa2e 2). ❑ Other(specify equipment t e and model in Section E on Page 2). Dispenser ID: 1-2 Dispenser ID: 3.4 © Dispenser Containment Sensor(s). Model: 794380-208 © Dispenser Containment Sensor(s). Model: 794380.208 D Shear Valve(s). © Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). 13 Dispenser Containment Floats and Chain(s). Dispenser 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 Floats and Chain(s), ❑ Dis enser Containment Floats and Chain(s) DispenserlD: Dispenser ID: 0 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 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): ® System set-up p Alarm history report Technician Name(print): ChrIS SanNICOIaS Signature: Certification No.: 833787 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: 3/20/2015 Monitoring System Certification Page 1 of 4 12/07 1