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f VFrriFR-RYAN Imc. 9 t Appendix VI OCT 18 2016 MONITORINGSYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California ENVIRONMENTAL HEALTH Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, cagEMIUWaj4T 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 SS 2093 Bldg. No.: Site Address: 3425 Tracy Blvd. City: Tracy zip: Facility Contact Person: Sarah Samuels Contact Phone No.: 360-526-3917 Make/Model of Monitoring System: TLS 35OR B. Inventory of Equipment Tested/Certified r:h—k fh® snnrnnrSafn h— fn indi-4- cn Mw Date of Testing/Servicing: 9!7/2016 Tank ID: T1- Reg Tank ID: T2 -Reg ® In -Tank Gauging Probe. Model: 846390-107 i% In -Tank Gauging Probe. Model: 846390-107 10 Annular Space or Vault Sensor. Model: 794390-409 ® Annular Space or Vault Sensor. Model: 794390-409 ® Piping Sump / Trench Sensor(s). Model: 794380-208 1% Piping Sump / Trench Sensor(s). Model: 794380-208 0 Fill Sump Sensor(s). Model: 794380-208 ® Fill Sump Sensor(s). Model: 794380-208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: 10 Electronic Line Leak Detector Model: 8484.80 ❑ Electronic Line Leak Detector Model: ® Tank Overfill / High -Level Sensor. Model: External IS Tank Overfill / High -Level Sensor. Model: External ❑ Other (setSiN 2quipment and model in Section E on Pa2e 2). ❑ Other s eci equipment type and model in Section E on Page 2). Tank ID: T3 -Reg Tank ID: T4 Sup ® In -Tank Gauging Probe. Model: 846390-107 ® In -Tank Gauging Probe. Model: 846390-107 ® Annular Space or Vault Sensor. Model: 794396-469 Annular Space or Vault Sensor. Model: 794390-409 O Piping Sump / Trench Sensor(s). Model: 794380-208 IM Piping Sump / Trench Sensor(s). Model: 794380.208 ® Fill Sump Sensor(s). Model: 794380-208 IM Fill Sump Sensor(s). Model: 794380.208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector Model: ® Electronic Line Leak Detector Model: 8484-80 M Tank Overfill / High -Level Sensor. Model: External III Tank Overfill / High -Level Sensor. Model: External ❑ Other (specify 2qui ment a and model in Section E on Page 2). ❑ Other (speai ui mart a and model in Section E on Page 2). Dispenser ID: 1/2 Dispenser ID: 3/4 M Dispenser Containment Sensor(s). Model: 794380-208 12 Dispenser Containment Sensor(s). Model: 794380-208 13 Shear Valve(s). IM Shear Valve(s). ❑ Dis eraser Containment Floats and Chain(s), ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: 5/6 Dispenser ID: 7/8 13 Dispenser Containment Sensor(s). Model: 794380-208 IR Dispenser Containment Sensor(s). Model 794380-208 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: DispenserlD: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dis enser Containment Floats and Chain(s). ❑ Dis enser Containment Floats and Chain(s). 11 UIC IGUI1ly W111411M MkNe WIIR5 Ui U15pCn5e15, copy mis form. mcivae mTormauon Tor every Tanx ana dispenser at the faciuly. 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 verify 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 ® Alarm history report Technician Name (print): GilbertGarcia Signature: T- - Certification No.: 8211864 -UT 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: 9/7/2016 Monitoring System Certification Page 1 of 4 12/07