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6f rTi ER - RYAN INC. GR Job # Appendix VI RECOVEL MONITORING TIF! i OCT 05 2015 For Use By All Jurisdictions Within the State of Ca/ifomia Authority Cited, Chapter 6.7, Health and safety Code; Chapter 16, Division 3, Title 23,E Regulations ''C"®T`r•,cgA 7jACAIr 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 2093 Bldg. No.: Site Address: 3425 Tracy Blvd City: Tracy Zip: Facility Contact Person: Contact Phone No.. Make/Model of Monitoring System: VR TLS 350-R Date of Testing/Servicing: 9/8/2015 B. Inventory of Equipment Tested/Certified Tank 10: 1-87 Main Tank ID: 2.87 Aux ® ® In -Tank Gauging Probe. Model: 846390-107 ® In -Tank Gauging Probe. Model: 847390-107 Annular Space or Vault Sensor. Model: 794390-409 a Annular Space or Vault Sensor. Model: 794390.409 ® Piping Sump / Trench Sensor(s). Model: 794380-208 LAI 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: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector Madel: 848480 ❑ Electronic Line Leak Detector Model: ® Tank Overfill / High -Level Sensor. Model: VR ® Tank Overfill / High -Level Sensor, Model: VR ❑ Others equipment and model in Section E on Page 21. ❑ Other Lspecify equipment and model in Section E on Pa2e 2). Tank ID: 3 -Siphon Tank ID: 4-91 ® In -Tank Gauging Probe. Model: 847390-107 ® In -Tank Gauging Probe. Model: 847390-107 !at Annular Space or Vault Sensor. Model: 794390.409 ® Annular Space or Vault Sensor. Model: 794390-409 ® Piping Sump / Trench Sensor(s). Model: 794380-208 IE Piping Sump / Trench Sensor(s). Model: 794380-208 ® Fill Sump Sensor(s). Model: 794380-208 Cd Fill Sump Sensor(s). Model: 794380-208 13Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector Model: ® Electronic Line Leak Detector Model: 848480 ® Tank Overfill / High -Level Sensor. Model: VR ® Tank Overfill / High -Level Sensor. Model: VR ® Other (specify ui ment type and model in Section E on Page 2). ❑ Other (soecA 2 ui ment DTe 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 ® Shear Valve(s). ® Shear Valve(s). ❑ Dis enser Containment Flats and Chains . ❑ Dispenser Containment Floats and Chains . Dispenser ID: 5 6 Dispenser iD: 7-8 ® Dispenser Containment Sensor(s). Model: 794380-208 ix't Dispenser Containment Sensor(s). Model: 794380-208 ® Shear Valve(s). ® Shear Valve(s). ❑ DisE2nser Containment Floa s and Chain(s). ❑ Dise2nser Containment Float(s) and Chaln s . Dispenser ID: 7rDispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chains). ❑ Dis nser Containment Float(s) and Chain(s). .. u �� --y —1-- n i w„ ., vmPcnmaas, wpy uns Tuan. ,ncauoe enrormatlon Tor 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 verify that this information is correct and a Piot Pian 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): Chris SanNieolas Signature: Certification No.: B33787 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: 9/8/2015 Monitoring System Certification Page 1 of 4 12107