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a6EllLER-RYAN INC. Appendix VI GR Job # 20-643211 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, 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 forth to the local agency regulating LIST systems within 30 days of test date. A. General 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.. 209-333-8088 Make/Model of Monitoring System: LC11000 Date of Testing/Servicing: 12/9/2016 B. Inventory of Equipment Tesled/Cerbfied Check the aooroorlats boxes to Indicate soeciflc eculoment Insoected/sarviced: Tank to: Diesel Tank ID: ❑ In -Tank Gauging Probe. Model: M In -Tank Gauging Probe. Model: M Annular Space or Vault Sensor. Model: LS600-LD-SN © Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(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: M Tank Overfill / High -Level Sensor. Model: Flapper ❑ Tank Overfill / High -Level Sensor Model: ❑ Other (specify equipment type and model in Section E on Pae 2 ❑ Other (specify equipment a and model in Section Eon Pa a 2. Tank ID: Tank ID: ❑ 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 Sensar(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(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: ❑ Tank Overfill I High -Level Sensor. Model: ❑ Other (specify ui ment type and model in Section E on Page 2).__ ❑ Other (specify equipment type and model in Section E on Pae 2). Olspenser ID: Dispenser to: M Dispenser Containment Sensor(s). Model: m Dispenser Containment Sensor(s). Model. IM Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chains DlspenserlD: Dispenser 10: ❑ Dispenser Containment Sensor(sl. Model ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valm(s). ❑ Shear Valve(s). ❑ Dispenser Containment Fioat s and Chain(s). 11 ❑ Dispenser Containment Floats and Chains Dispenser to: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear VaNe(s). ❑ Dispenser Containment Floats antl Chains . ❑ Dispenser Containment Floats and Chain(s). If the reality contains more tanks or dispensers, copy this form. Indude information for every tank and dispenser at the facility. C. Certlflration - I certify that the equipment Identified In this document was inspectetl/servlced 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 (print): Jose Carrasco Signature: l Certification No.: 835934 License. 1 220793 Testing Company Name: Gettler-Ryan Inc, PhoneNo.:925-551-7555 Testing Company Address. 6805 Sierra Court Suite G, Dublin, Ca. 94568 Date of Testing/Sentiang: 1 21912 01 6 Monitoring System Certification Page t of 4 RECEIVED DFC262017 ENVIRONMENTAL HEALTH 0FPARTMFNT