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6 VE771ER-RYA N INC. Appendix VI 0 GR Job # 10-062101.1 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, Califomia 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: TLS 350-R Date of Testing/Servicing: 9/16/2014 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 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 a8 that apply): ® System set-up IM Alarm history report Technician Name (print): ElodiO Sanchez Signature: Certification No.: 841204 License. No.: 220793 Testing Company Nam: Gettler-Ryan Inc. Phone No.: 925-551-7555 Testing Company Address: 6805 Sierra Court Suite G., Dublin, CA 94568 Date of T (;-. Monitoring System Certification Page 1 of 4 Z 0 ( 12107 check tne appropriate boxes to maicate specmc e uimem ms sernceo: Tank ID: 87-1 Tank 10: 87-2 12 In -Tank Gauging Probe. Model: 847300-107 ® In -Tank Gauging Probe. Model: 847390.107 O Annular Space or Vault Sensor. Model: 794390-407 IM Annular Space or Vault Sensor. Model: 794390407 13 Piping Sump / Trench Sensor(s). Motel: 794380.208 ® Piping Sump / Trench Sensor(s). Model: 794380-208 Q Fill Sump Sensor(s). Model: 7"311164W 19 Fill Sump Sensor(s). Model: 794380-344 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: 19 Electronic Line Leak Detector Model: 848480 ❑ Electronic Line Leak Detector Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Pa 2). ❑ Other equipment and model in Section Eon Pa e 2. Tank ID: 91 Tank ID: ® in -Tank Gauging Probe. Model: 847390-107 ❑ in -Tank Gauging Probe. Model: IN Annular Space or Vault Sensor. Model: 7004ff ❑ Annular Space or Vault Sensor. Model: 19 Piping Sump/ Trench Sensor(s). Model: 79-4-3-W-2-03 ❑ Piping Sump / Trench Sensor(s). Model: 13 Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Mei: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector Mel: 848480 ❑ Electronic Line Leak Detector Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Others ui ment typg and model in Section E on Page 2). ❑ Other (specify eguipment W22 and model in Section Eon Page 2L Dispenser ID: 1-2 Dispenser ID: 3-4 111 Dispenser Containment Sensor(s). Model: 794380.208 ® Dispenser Containment Sensor(s). Model: 794380-208 ® Shear Valve(s). ® Shear Valve(s). ❑ Disp2nser Containment Flocs and Chain(s). ❑ Dispenser Containment noa s and Chain(s). DlspenserlD: Dispenser ID: 7-8 ® Dispenser Containment Sensor(s). Model: 794380-208 12 Dispenser Containment Sensor(s). Model: 794380.208 M Shear Valve(s). IM Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Flo! s and Chat s . Dispenser 10: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floa s and Chai s . ❑ Dispenser Containment Floa 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 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 a8 that apply): ® System set-up IM Alarm history report Technician Name (print): ElodiO Sanchez Signature: Certification No.: 841204 License. No.: 220793 Testing Company Nam: Gettler-Ryan Inc. Phone No.: 925-551-7555 Testing Company Address: 6805 Sierra Court Suite G., Dublin, CA 94568 Date of T (;-. Monitoring System Certification Page 1 of 4 Z 0 ( 12107