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®6EYTifR-RYAN INC. GR Job # 17204947 Appendix VI swttc , MONITORING SYSTEM CERTIFICATION ilt sas L) For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 18, Division 3, Title 23, California; Code of 01 B Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification orrree�� must be prepared for HEALTH each monitoring system control panel by the technician who performs the work. A copy of this form must be I= ad 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. -NT A. General information Facility Name: Dart Container Corp Slmaddress: 1400 E. Victor Rd city: Lodi Fadlity Contact Person: Daryl Lee Conrad Phone No.: Bldg. No.: _Zip 95240 415-902-5089 Make/Model of Monitonng System: Pneurnercator Date of Testing/Senacing'. B. Inventory of Equipment Tested/Certified 12/26/2017 - team ins caaeemesa: Tank ID: DSL Tank ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ to: In-Tonk Gauging Probe. Model: Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: Fill Sump Sensoria). Model: Mechanical Line Leak Detector. Model: Elecbonk Line Leak Detector Model: Tank Overfill / High -Level Sensor. Model: Other (specify equipment and model in SecUai E on Pace 2 In -Tank Gauging Probe. Model: i Annular Space or Vault Sensor. Model: LTT,S Piping Sump / Trench Sensw(s). Model: Fill Sump Sensoria). Mode: Mechanical Line Leak Detector, Model: Electronic Line Leak Detector Model: Tank Overfill / High -Level Sensor. Model: Other (specify equipment type and model in Section E on Pa 2 . TanklD: TanklD: In -Tank Gauging Probe. Model: Annular Specs or Vault Sensor. Mode: Piping Sump/ Trench Senors). Model: Fill Sump SensaKs). Mode: Mechanical Line Leak Detector. Model. Electronic Line Leak Detector Mode: Tank Overfill / High -Level Sensor. Mode: Other (specify ui men! and model in Section E on Pa e 2= ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ In -Tank Gauging Probe. Mode: Annular Space or Vault Sensor. Mode: Piping Sump/ Trench Senam(s). Model: Fill Sump Sensor(s). Modal: Mechanical Line Leak Detector. Model: Electronic Line Leak Detector Mode: Tank Overfill / High -Level Sensor. Mode: Omer smCiff eills!Dft"pe and model in Section _Eon Page 2). Dispenser to: Dispenser ID: Dispenser Containment Sensons). Model: Shear Valve(s). Dispenser Containment Floats and Chain(s), — ❑ ❑ ❑ Dispenser Containment Sensoria). Model Shear Valve(s). Dispenser Containment Flo s and Chains . Dispenser to: DlePenaer ID: Dispenser Containment Sensors). ModeC Shear Valve(s). DisE±nser Containment Floats and Chains Q ❑ Q Dispenser Containment Sensor(s). Mode: Shear Valve(s). Dispenser Containment Float(s) and Cham(s). Dispenser ID: DlspenserlD: Dispenser Commitment Sensor(s). Shear Valve(s). Model: Q ❑ Dispenser Containment Sensor(s), Shear Valve(s). Model: Dispenser Containmen ispenser Containment Floats and Chains me acmryconams more tans or mspensers, copy this roan. Include information for everytank and dispenser at the facility, C. Certification - I certify that the equipment Idemitied In this document was Inspectad/aarviced In accordance wfih 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 ofthe report (check all that appy): E System set-up 0 Alarm Watoryrepod; Technician Name (pant)'.Alexander Tate Signature Certification No.: B42662 License. No.: 220793 Testing Company Name: Gettler-Ryan Inc. Phone No.: 925-551.7555 Testing Company Address: 6805 Sierra Court Suite G., Dublin CA 94568 Dam of Testintl/Servidng: 12/26/2017 Monitoring System Certification Page 1 of 4 12107