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19255517888 Main Fax GETTLER RYAN INC 09:07:41 a.m. 10-03-2007 2/4 41 A NITORINU SYSTEM CERTIFICATION 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 Regulgttons,.... This form must be used to document testing and servicing of monitoring equipment. ,6 &gate certification or r rt must Mar cd for each monitoring system control Rand 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 Site Address: _3425 Tracy Blvd. Facility Contact Person: City: Tracy Zip: Contact Phone No.: ( Make/Model of Monitoring System: _TLS 350 Date of Testing/Servicing: —09—/-27—/-07— B. 09/_27_/_07_ Bldg. No.: B. Inventory of Equipment Tested/Certified Tank ID: _87 Oct Siphon U In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor, Model: X Piping Sump / Trench Sensor(s). Model:7943gO zft ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: O Other (specify equipment type and model in Section E on Page 21, Tank lD: O In -Tank Gauging Probe. Model: O Annular Space or Vault Sensor. Model: Q Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ "rank Overfill / High -Level Sensor. Model: ❑ Other (specify equiprrtent type and ntodet in Section E on Page 2). Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: D Shear Valve(s). O Dispenser Containment Floats) and Chain(s). Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: O Shear Valve(s). O Dispenser Containment Floats) and Chain(s). Dispenser ID: Cl Dispenser Containment Sensor(s), Model: O Shear Valve(s). ❑Dispenser Containment Float(s) and Chants). 'If the facility contains more tanks or dispensers, copy this form. Include Tank ID: O In -Tank Gauging Probe. Model: O Annular Space or Vault Sensor. Model: O Piping Sump / Trench Sensor(s), Model: 13 Fill Sump Sensor(s). Model: O Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor Model: Cl Other (specify equipment type and model in Section E on Pahze 2). Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: O Piping Sump / Trench Sensor(s). Model: Q Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: O Electronic Line Leak Detector. Model: O Tank Overfill / High -Level Sensor. Model: Q Other (specify equipment type and model in Section E on Page 2). Dispenser ID: Q Dispenser Containment Sensor(s)_ Model: Q Shear Valve(s). Q Dispenser Containment Floats) and Chain(s). Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: Q Shear Valve(s). O Dispenser Containment Float(s) and Chain(s). Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Dispenses Containment Floats) and Chaitt(s). formation for every tank and dispenser at the facility M� kft . If more than one ) i monitoring system control panel is installed at the facility, a },.,�.,-,,.....,w.�snucrions are...., printed on the back of this ! page -1 { Dt : C. Certification - I certify that the equipment identified in this document was inspected/serviced In accordance with the mannfaeturers' guidelines. Attached to this Certifksttion is information (eg. rrmoufactureW checklists) necessary to verify that this information is correct and a 'lot Pin shovr the out of monrto ai ment Foran , of ... t ca _ ble of erceratin such I have also r-.._ ............._..._..._........_._.........._._ _......,� .................!aS..........Y.........._.........ri?!g.e4...P......._..............Y.e9...Pmn......PA..........g..............il.........!cAo!?st._..................... , Oeletnd: site attached a copy of the report; (check all that apply): O System set-up O Alarm history report Technician Name (print): Mike Prattt nature: ,-7 r_._.............._........._........._............._..__� g- - .. `s��%Cert./Uc.No.: C"r[ificatiun NU.:. 5252315 -UT License. No.:. ��....._.._.._...................._......................_....__...... Testing Company Name: _GET TLER RYAN INC. Phone No.:{_925_551-4777 me Address: �a !7-1 ��/e�y� jJ �' f /, . /// Date ofTesting/Servicing: _04 !' 27 / 07_ _............ �� r ... . Page 1 of 3 11"t Monitoring System Certification