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ig6frran-RYAN INC. GR Job# 18202542 Appendix VI SWRCB,January 2000 MONITORING 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 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 LIST systems within 30 days of test date A General Information Facility Name Arco 2093 Bidg.No. Site Address 3425 Tracy Blvd. city. Tracy zip- 95376 Facility Contact Person Daryl Lee Contact Phone t lit.. 415-902-5089 Make/Model of Monitoring System TLS-350 Date of Testing/Servicing. 8/30/2018 B. Inventory of Equipment Tested/Certified Check the aPPME18110 boxes to indicate sggciflc ui ment Ins etedfserviced: Tank ID: 87 Tank ID: 87 in-Tank Gauging Probe f;Aodel• 842320-302 ® to-Tank Gauging Probe. Model* 847390-107 If Annular Space or Vault Sensor. Model: 79439Q-4Q2— 0 Annular Space or Vault Sensor. Model: 7 94 3 9 0-4 0 9 Pip ng Stump 1 Trench Senser(s), Model: 72438Q-208 ® Piping Sumpl Trench Sensor(s). Model: 794380-2Q8 Fill Sump Sensors) Model, 79 4 3 8 0-2 0 8 ® Fill Sump Sensor(s). Model, 794]80-208 Mechanical Line Leak Detector Model: 13 Mechanical line Leak Detector. Model: r Electronic Line Leak Detector Model8 4 84 8 0 O Electron Line Leak Detector Model: Tank Overfill!High-Level Sensor Modet QTR @ Tank Overfill High-Level Sensor Model: tE Other(seecuipment tyEe and model In Section E on Pa 2). ® Other(specify ut ment tM2 and model in Section E on Page 21, Tank 10: AZ Tank la 91 In-Tank Gauging Probe Model. 847390-107 ® In-Tank Gauging Probe Model, 847390-107 Annular Space or Vault Sensor. Model: - ® Annular Space or Vault Sensor Model: 79139Q-4Q2 i Piping Sump d Trench Sensor(s). Model- '794580-209— ® Piping Sump/Trench Sensor(s) Model, 791300-20a 7 Fin Sump Sensors) Model: 9�-2 0 8 ® Fill Sump Sensor(s) Model: 72j30()-20B Mechanical Line Leak Detector. Model: ® Mechanical Line Leak Detector Model Electronic Line Leak Detector Model: 848480 _ ® Electronic Lite Leak Detector Model 8 4 8 4 8 0 iTank Overfill/High-Level Sensor I: R GO Tank OverfA t High-Level Sensor Model: QTR Other(specify equipment t and model in Section E on P290 2). ® Other(sviecteguipmenti a and model to Section E on P e 2 DispenserlD: 1-2 Dispenser 10* L-4 Dispenser Containment Sensors)- Model: 7 9j3&0-2 0 8 ® Dispenser Containment Sensors). Model 794380-208 Shear Valve(s) ® Shear Vaive(s). Di nser Containment Float(s)and Ghaan s. ® Dispenser Containment Floats and Chainis) Dispenser 110: 5-6 Dispenser to: 7-8 i Dispenser Containment Sensor(s) Model: 794380-209 ® Dispenser Containment Sensor(s) Model 794380-208 i Shear Valve(s) ® Shear Valve(s) Dispenser Containment Floats and Chat s. ® D12onser Containment Float(st and Chain(s) Dispenser 10: Dispenser ID: Dispenser Containment Sensors). Model. ® Dispenser Containment Sensors). Model: Shear Valve(s) ® Shear Valves) Dispenser Containment Floats and Chain(s). D Dis eraser Containment Floats and Cha s If the facility contAns more tanks or dispensers.copy this form.Include information for every tank and dispenser at the facility C Certification - I certity 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 jpat this Information Is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of gene ng au reports, I have also attached a copy of the report;(check all that apply): [] system set-up 1] Ain rm hi report Technician Name(print) David Rouse Signature Certification No. VR#B44848 ICC#8292530 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 DateofTestitg/Se ng 810/2019 Monitoring System Certification Page i of 4 t2fI7 1