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AUG-20-2007 02 :06 PM GETTLER-RYAN INC. 925 551 4770 P. 02 MONITORING SYSTEM CEk TIFICATION P'or Use fat•AN Jurisdictions Within thr Steele of'California Atahnrily Cited: Chapter 6,7, Health and Stifc•tr(.'nde:Chapter itis I)ivi.sion 3, Title 23, C(jlift)rnia Cock'of&gulalions This farm must be used to document testing and servicing of monitoring equiptnent.A separate ifl ate ion or r must bep� rid for each moBitodpi;5yst,0,M l;,=9(. 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 s/Mems within 30 days of test date. A. General Information Facility Name: -- ARCO 0 6080 Bldg, No.:___-.- 85 E LATHROP AVE LATHROP Site Address;-- _. City:.__ ,,,..._.. Zip: -..__._...._.,_. Facility Contact Person: �._ ---------._.. . _.. _..--- C•iMac[Phone No.: (•---.-)�,r^--.-.-- MakeiModel of Monitoring System: TLS 850 f)utc.of'resting/Servicing: B. Inventory of Equipment"tested/Certified Check die somorlste boxea to indicates lite a ul ment lax ectettiserviced: r Tank In: 81 FILL SUMP 'rank ID: ❑In-Tank Gauging Probe. Mudri:_ - -�-. -_ ❑ In-Tank Guuging Probe, Model ,-,-- ❑Annular Space or Vault Sensor. M(Ael: ...__, _--_.-_- ❑ Annular Spaa or Vtiull Sensor. Mesial; -__- ❑Piping Sump/Trench Sensor(0. Model_ -_--__--__,-_ ❑ Piping Sump/Trench Sensor(s). Model: ^- Q Fill Sump Sensor(s). Model 20741.9 _ _-_ ❑ Fill Sump Sensor(%). M(xlcL ❑Mechanical Line Leak Detector, Model:_ _ wchunical Linc Letik Detector. Modcl: Electronic Line Line Leak Detector. Model:_ T e Electronic Lute Leak Detector. Model: Tank Overfill/High-Level Sensor. Model,•_~R - - --____- ❑ Tank 0Rerfill/High-Lcvel Sensor. Mulct: --- Other(s cil• equipment t e and model in Section F.un Pa c 2). ❑ Other(s)e ily equip stent type and m(xlclinin Sce icn E on Page 21, Tank 1D: _ _ Tank iD•— -- --- --•- ❑In-Tank Gauging Probe, m(ldcl: _-.. ..--_ ❑ In-Tank Gauging,Probe, Model: ❑Annular Space or Vault Sensor. Mtxlel: - ❑ Annular Space or Vault Sensor. Model: --- ❑Piping Sump/Trench Sensor(s). Model; - .-_-.---__ ❑ Piping Sunip/Trcnch Sensoroo. Model; ❑Fill Sump Sensor(s). Model;___ _-_-.-_ ❑ Fill Surnp Svrksorm. Model: ❑Mechanical Lint:Leak Detector. Model:., ❑ Mechanical Linc Lcak Detector. Mixicl; ❑ Electronic Line leak Detector. Madel: -_... - - ❑ Electronic Line Leak Detector, Model:�..------- ❑Tank Overfill/High-Uvcl Sensor, Model: _ �] Tank Ovcrfill/High-Lavcl Senutr. Model: ❑Other(specify c ui.meat t rand mesial in Section R un Pa,c 31, ❑ Uthcr(s.)ecif c ui menL t and model in Section E on Page?). Dispenser ID:-. _. --..._..- Dispenser ID .� -.--- - - - T--- ❑Dispenser•Containment Sunsor(s).uModd;!_ --- ❑ Dispenser('untaimncnt Sensor(%). Model: .,,.�_-.._ ❑Shear Valv0s). ❑ Shear Vahc(s). ❑Disporr4er Containment Float(s)and Chain(al, ❑ Dispenser nser Containincnt Float(m and Chain(s). Dlspenaer 1D: ---.--_.-_.. Dispen_ver ID:a ❑Dispenser Containment Sensor(s). Model: R Dispenser Containment Sensutl4), El Shear Valve(s). U Shear Valvc(sl. Dis •nwrContainmcnt Flouts)And Chain s). ❑ Uucn c Containment Float(%)and Chain(s), Dispenser ID: _ __---- ___--- I Dispenser iD: - DisprnserC'ontaintnent Sensor(%). Miulel:_- _ _.._____ ❑ Dispct►scr('ontaimnent Sensor(%). Model:.-.,.._---_,.--- Shear Volve(s), ❑ Shcau Valvc(s), [his nser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)attd Chain(s). . "if tlu facility contains more tanks or dispensers,copy this form. Include informallon lir avery tank and dispenser tit the facility. C. Certification -I certify that the equipment Identliled in this document was inspected/serviced in accordance with the ntanufacturet•s' guidelines. Attached to this Certification is information (e.g. nprnufacturers' checklists) necessary to verify that this Information Is correct and it Plot Plan Showing the layout of monitoring Lquipment. For any equipment capable of generating web reports,I have also attached a copy of the report;(check aU that apply): ❑System set-up ❑Alarm history report 'Technician Name(print):�!eruuer+�,-___, _.--._...__- Signature: A38320 License. No... 220703 -_-� Certification No.: _ _ - -----. --� -- —""' G&ffLER-RYAN INC. Phone No.:� B1° b61-rsle Testing Company Name:._-- --- - Site Address: __ __-- --.-._..-..----- --- - -- Date of Testin)*JServicing: -_/.._J-_. Page 14,31 ONO Monlioting System Certification