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w ®GErrLFR-RrREGEAN INC. # " 17204947 FEB 0 ��IO�f� Appendix VI SWRCB, January 2006 MONITORING SYSTEM&ARM10MONHEAt-TH For Use By All Jurisdictions Within the Star AMMENT Authority Cited: Chapter 6.7, Health and Safety Code, Chapter B, Division 3, Title 23, Callfomla 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: Dart Bldg. No.: Site Address: 1400 E. Victor Rd City: Lodi Zip: 95420 Facility Contact Person Daryl Lee Confect Phone No.: 415-902-5089 Maka/Model of Manitonng Systam: Dab of Testing/Servidng: B. Inventory of Equipment Tested/Certified Check the aooroodata rosea to hau,—Is, i.._......._ TanklD: Diesel Tank ID: In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Prebe. Model: I Annular Space or Vault Sensor. Model: LS7 ❑ Annular Space or Vault Sensor. Model: Piping Sump/ Trench Sensoria). Model: ❑ Piping Sump/ Trench Sensor(s). Model: Fell Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Modal: Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: Electronic Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: I Tank Overfill/High-Level Sensor Model: Fl annex ❑ Tank Overfill/High-Level Sensor Model: Others a ui ment end model in Section E on Pa e 2 . ❑ ethers equipment and model in Section E on Ps 2 Tank ID: Tank 10: In -Tank Gauging Probe. Model, ❑ In -Tank Gauging Prebe, Model: Annular Space or Vault Sensor. Model: ❑ Annular Spann or Vault Sensor. Model: Piping Sump /Trench Sensor(s). Model ❑ Piping Sump/ Trench Sensor(s). Model. F01 Sump Sensor(a). Madel: ❑ Fill Sump Sensor(s). Made': Mechanical Line Leak Detador. Model: ❑ Mechanical Line Leek Detector. Model: Electronic Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: Other a ' e ui ment and model in Section E on Pa e 2 . ❑ Others a ui ment and model in Section E on Page 2), Dlapen ser l D: Dispenser 10: Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sansor(s). Modal: Shear Velve(s). ❑ Shear Velve(s). Dis sneer Containment Floats and Chain(s). ❑ D isser Containment Floats and Chain a . Dispenser ID- Chips naar to: Dispenser Containment Sensor(s). Modd: ❑ Dispenser Containment Sensor(s). Mode': Shear Valw(s). 0 Shear Valwis). Dis ser Containment Floats and Chain(s). 0 Dispenser Containment Float(s) and Chains). Dtepa : Dispenser lD: Dispenser lspenaer Cpnbinment Sensor(s). Model: ❑ Dispenser Canbinment Sensor(s). Madel: Sheer Valve(s). Q Shear Valve(s). Dis nser Containment Floa s and Chain(s), ❑ Dispenser Containment Floats) and Chain(s). �i aye a64, wriwine mune ranks or orspensers, copy this form. Include infannston for every tank and dispenser at the facility. C. Certification - I certify that the equlpmem Identified In this document wee Inspected/aervicad 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 Plan showing the layout of monitoring equipment For any equipment capable of generating su h reports, I he. also aCached a copy of the report; (check all that apply): 0 System setup 21 Alarm history report Technician Name (prim): ElOdto SaticheZ Signature: 4�A Certification No.: 11260 License, No.: 220793 Testing Company Name: Getter -Ryan Inc. Phone Ne.: 925-551-7555 Testing company Address_ 6805 Sierra Court Suite G., Dublin CA 94568 Date of Testing/Servicing: 12/29/2017 Monitoring System Certification Page 1 of 4 12/07