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ig GErTtiR-RYAN INC. GR Job # 20-643211 Appendix VI ECEIVED MONITORING SYSTEM CERTIFICATION - For Use By AA Jurisdictions Within the Stale of California JAN 1 3 2017 Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations ENVIRONMENTAL HEALTH This form must be used to document testing and servicing of monitoring equipment. A separate certification or r�Q fyl(Gf for each monitoring system control panel by the technician who performs the work. A copy of this Form must be prb6itled'tlf'th8'farifc 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. Geneml Information Facility Name: Dart Container Corp. Bldg, No.: Site Address: 1400 E. Victor Road city: Lodi zip: Facility Contact Person: Robert Vargas Contact Phone No.: Make/Model of Monitoring System: LC1000 B. Inventory of Equipment Tested/Certified Ch 209-333-8088 Date of Testing/Servicing: 121912016 It the facility contains more tanks or dispensers, copy this form. Include information for every lank 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. manufacturerschecklists) necessary to verity 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 (pdnq: JOSE CarrdeCO Signature. Certification No.: 835934 License. No.: 220793 Testing Company Name'. Gettler-Ryan Inc. Phone No 925-551-7555 Tesfing Company Address: 6805 Sierra Court Suite G, Dublin, Ca. 94568 Date of Testing/Serviang: 1 2/912 01 6 Monitoring System Certification Page t of 4 12107 eck the appropriate boxes to Indicate specrrm equipment mspeciemservrcea: Tank ID: Diesel Tank ID: ❑ In -Tank Gauging Probe. Model. IM In -Tank Gauging Probe. Model. D Annular Space or Vault Sensor. Model: LS600-LD-SN 10 Annular Space or Vault Sensor. Model: ❑ Piping Sump/ Trench Sensor(s). Model: ❑ Piping Sump/ Trench Sensor(s). Model: ❑ Fill Sump Sensar(s). Model : ❑ Fill Sump Sensor(s). Model. ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector Model: ❑ Electronic Line Leak Detector Model. © Tank Overfill / High -Level Sensor. Model: Flapper ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other(specify ui merit a and model in Section Eon Pae 2). ❑ Other(specify equipment and model in Section E on Pae 2 TanklD: TenklD: ❑ 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). Motlel'. ❑ Fill Sump Sensor(s). Model. ❑ Mechanical Line Leak Detector. Model'. ❑ Mechanical Line Leak Detector. Model. ❑ Electronic Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: ❑ Tank Overfill / High -Level Sensor. Model. ❑ Tank Overall / High -Level Sensor. Model. ❑ Other(specify equipment and model in Section E on Page 2). ❑Omer s e � ui mens type and model in Section E on Page 2 Dispenser ID: Dispenser to: Int Dispenser Containment Sensor(s), Model: Ed Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Floahs) and Chemist DispenserlD: Dispenser ID: ❑ Dispenser Containment Sensors). Motlel. ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chants). ❑ Dispenser Containment Float(s) and Chaints7. Dispenser ID. Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chains . ❑ Dispenser Containment Floats and Chains. It the facility contains more tanks or dispensers, copy this form. Include information for every lank 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. manufacturerschecklists) necessary to verity 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 (pdnq: JOSE CarrdeCO Signature. Certification No.: 835934 License. No.: 220793 Testing Company Name'. Gettler-Ryan Inc. Phone No 925-551-7555 Tesfing Company Address: 6805 Sierra Court Suite G, Dublin, Ca. 94568 Date of Testing/Serviang: 1 2/912 01 6 Monitoring System Certification Page t of 4 12107