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Girua-RYAN IHC. Appendix Vi ft, Job # 10-062101 MONITORING STEM 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 UST systems within 30 days of test date. A. General information Facility Name: Arco 5450 Bldg. No.: Site Address: 1617 W Fremont City Stockton zip: Facility Contact Person: Contact Phone No.: Make/Model of Monitoring System: VR TLS35OR Date of Testing/Servicing: 9/12/2014 B. Inventory of Equipment Tested/Certified ' If the facility contains more tanks or dispensers, copy this form. include Information for 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 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): Chris SanN(eoias Signature: Certification No.: 833787 Testing Company Name: License. No.: 220793 Gettler-Ryan Inc. Phone No.: 925-551-7555 Testing Company Address: 6805 Blatta Court Suite G., Dublin, CA 94568 Date of Testing/S fECEWEwb- Mooltoring System Certification Page 1 of 4 12107 t � k %.necx the appropnerle coxes zo moicam Specmc ur mene ms cceorservrcea: Tank 10: 1-87 Tank ID: 247 m In -Tank Gauging Probe. Model: 847390107 ® In -Tank Gauging Prole. Model: 846380-107 ❑ Annular Space or Vault Sensor. Madel: ❑ Annular Space or Vault Sensor. Model: © Piping Sump /Trench Sensor(s). Model: 794386 208 ® Piping Sump/ Trench Sensor(s). Model: 794380208 ® Fill Sump Sensor(s). Model: 7 ® Fill Sump Sensor(s). Model: 794380-344 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector Model: 8484-80 ❑ Electronic Line Leak Detector Model: L13 Tank Overfill / High -Level Sensor. Model: ® Tank Overfill / High -Level Sensor. Model; VR ❑ Others ui ment and model in Section E on Pae 2). ❑ Other(specifyul ment a and model in Section Tank ID: 3-91 Tank 10: © in -Tank Gauging Probe. Model: 846390-107 ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ® Piping Sump / Trench Sensor(s). Model: 794380208 ❑ Piping Sump / Trench Sensor(s). Model: ® Fill Sump Sensor(s). Model: 784380.344 ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector Model: 114= ❑ Electronic Line Leak Detector Model: ® Tank Overfill / High -Level Sensor. Model: VR ❑ Tank Overfill! High -Level Sensor. Madel: ❑ Other (Necify equipment We and model in Section E on Pae 2). ❑ other (specify equipment and model in Section E on Pa e 2 . DispenserID: 1-2 DlspermeriD: 3-4 ® Dispenser Containment Sensor(s). Model: 794380208 12 Dispenser Containment Sensor(s). Model: 794380208 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Floes and Chain(s . ❑ Dispenser Containment Fba s and Chains . Disperser ID: 5-6 Dispenser ID: 7.8 ® Dispenser Containment Sensor(s). Model: 794380208 IN Dispenser Containment Sensor(s). Model: 794380208 IM Shear Valve(s). IM Shear Valve(s). ❑ Dispenser Containment Floa s and Chain(s). ❑ Dispenser Containment Floaqsj and Chain(s). nser ID: Dispenser ID: [[3 Dispenser Containment Sensor(s). Model: E3Dispenser Containment Sensor(s). Model: Shear Valve(s). E3Shear Vaive(s).Dispenser Containment Float(s)and Chain(s). 13 Dispenser Containment Fkta s and Chain(s). ' If the facility contains more tanks or dispensers, copy this form. include Information for 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 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): Chris SanN(eoias Signature: Certification No.: 833787 Testing Company Name: License. No.: 220793 Gettler-Ryan Inc. Phone No.: 925-551-7555 Testing Company Address: 6805 Blatta Court Suite G., Dublin, CA 94568 Date of Testing/S fECEWEwb- Mooltoring System Certification Page 1 of 4 12107 t � k