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d 9255517888 Line :18:23 08-20-2012 2/4 0 0 A 6EMER-RYAN INC. Appendix V[ MONITORING SYSTEM CERTIFICATION For Use By Alt 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 UST systems within 30 days of test date. A. General Information Facility Name: Arco 5450 eldn Nn Site Address: 1617 W. Fremont Street city: Stockton Zip: Facility Contact Person: Site Attendant Contact Phone No.: Make/Model of Monitoring System; TLS 354 B. Inventory of Equipment Tested/Certifled Chock Oho Ann—h-ho hnvca M 1-11 4. c 10w n....:nn.a..6 I..n..-.-a...u....-.a.....:. Date of Testing/Servicing: 8/7/2012 Tank to: Unleaded T1 Tank ID: Premium T3 ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ 113 Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: 12 Electronic Line Leak Detector Model: $4840 ❑ Electronic Line Leak Detector Model: 848480 ❑ Tank Overfill / High -Levet Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other ec i ment po and model In Section E on Pae 2). Others i ment type and model in Section E on Pa TankiD: TanklD: ❑ In -Tank Gauging Probe. Model: ❑ in -Tank Gauging Probe. Model; ❑ Annular Space or Vault Sensor. Modes: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fig Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model; ❑ Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. I: E3 Electronic Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: ❑ Tank Overfill 1 High -Levet Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Others ui ment type and model in Section E on Page 2 . ❑ Other ispecify e u ent t ype and model in Section E on Dispenser 10; Dispenser to: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ® D' enser Containment Flo s and Chain(s). ❑ Dispenser Containment Floats and Chain(s). Dispenser to: Dispenser ID: ❑ Dispenser Containment Sensogs). Madel; ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Vaive(s). ❑ Dispenser Containment Floats and Chains . ❑ Dispenser Containment Floats and Chains . Dispenser ID: Dispenser 10: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shaw Valve(s). ❑ Dispenser Containment Floa s and Chain(s). ❑ Dis enser Containment Floats and Chain(s). n UIV IdUIRy WFUdIF1S mare tanrcs or alspensers. copy ims rorm. inciuoe iniormaaon for every tank ane 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 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): 0 System set-up m Alarm history report Technician Name (print): Jose Carrasco Signature: Certification No.: B35934 License. No.: 220793 Testing Company Name: Gettler-Ryan Inc. Phone No.: 525-551-7555 Testing Company Address: 6747 Sierra Court Suite J, Dublin, Ca. 94568 Date of Testing/Servicing: 8/7/2012 Monitoring System Cent icadon Page 1 of 4 I 12/07