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imGerttfrt-Ryax frac. Gni J (� 4 Appendix VI E 0 E117E D MONITORING SYSTEM CERTIFICATION DEC 21 2017 For Use By All Jurisdictions Within the Slate of Califomia Authority Cited: Chapter 6.7, Health and Safety Code;Chapter 16, Division 3, TE" ' Regulations � ALTH n F""n RTM E NT This fort must be used to document testing and servicing of monitoring equipment.A separate certificatlon 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 ownerloperator The ownerloperator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date A Generallnromtation Fac1ity Name: _Ryder 8392000 Bldg No.- x SlteAddress: 5655 Hood Way city Tracy Zip: 95377 Fau.•ty Contact Person. Contact Phone No. A Make/Model of Monitoring System: TLS-350 Date of TestinglServicing 11!1012017 B. Inventory of Equipment Tested)Certiried Check the appropriate boxes to indicate specific equipment Ins ecledfserviced: Tank ID: DSL Tank ID: ❑ in-Tank Gauging Probe. Model: ❑ In-Tank Gaug ng Probe Model 19 Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor Model ❑ Piping Sump I Trench Serim(s). Model: ❑ Pip ng Sump I Trench Senscgs). Model ❑ F+n Sump Sensor(s) Model: ❑ Fill Sump Sensors) Model ❑ Mechanical Line Leak Detector Model: ❑ Mechanical Line Leak Detector Model IM Electron c L ne Leak Detector Model: PLLD ❑ Electronic Line Leak Detector Model ❑ Tank Overfill I High-Level Sensor. Model: ❑ Tank Overfil I High-Level Sensor Model ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify, u poll type and model in Section E on Page 2 Tank ID: Tank ID. ❑ In-Tank Gauging Probe Mode,: ❑ In-Tank Gauging Probe Moder E3.. Annular Space or Vault Sensor. Model: ❑ Annu'ar Space or Vault Senior Model ❑ Aping Sump I Trench Sensor(s). Model: ❑ Piping Sump/Tfench Sensor(s) Model ❑ Fill Sump Sensor(s) Model: ❑ Ri Sump Sensor(s) Model ❑ Mechan.cal Line Leak Detector. Model: © Mechanical Line Leak Detector Model ❑ Electronic Line Leak Detector Model E3 Electi lc Line Leak Detector Model ❑" Tank Overfill f High-Level Sensor Model ❑ Tank Overfi.I I High-Level Sensor Model ❑ Other(specify ui ment a and model In Section E on Page 2). ❑ Others equipment a and model in Section E on Pae 21. Dispenser ID; Dispenser Il ❑.. Dispenser Conta nmeru Sensors) Model ❑ Uspenser Containment Sensor(s) Mode. ❑ Shear Valves) ❑ Shear Valves) Q Oks,penser Containment Floats and Chain(s). ❑ Drspensw Containment Floats and Chain s Dispenser ID: Dispenser ID: ❑ Dispenser Containment Senszu(s) Model ❑ Dispenser Containment Sensors) Modell ❑" Shear Valves) © Shear Valve{s) 0 Dls eraser Containment Floats and Chains ❑ Di nser Contanment Floats and Chain(s). Dispenser ID: Dispenser ID: Q Dispenser Containment Sensor(s). Model ❑ Dispenser Containment Sensor(s) Moder ❑.. Shear Valve(s) ❑ Shear Vaive(s) ❑ Dispenser Conta nment Floats and Chains. ❑ D spenser Containment Floats and Chair if the facility contains more tanks or dispensers,copy this form Include informaUcin 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' checkllsts) 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): p System set-up p Alarm history report acL,ur w Technician Name(print) Alexander Tate Signature - - Cerlification No• 842662 License No 220793 Testing Company Name• Gettler-Ryan Inc. Phone No 925-551-7555 Testing Company Address 6805 Sierra Court#G, Dublin,CA 94568 Date of TeslinglServlcing Monitoring System Certification Page 1 of 4 12107 1