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®6irrlFd-RYAN INC. n,1\I 2 2D19 GR Job# 18200072 Appendix VI SWRCB,January 2006 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 form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: Arco 6080 Bldg.No.: Site Address: 85 E. Louise Ave City: Lathrop Zip: 95330 Facility Contact Person: Daryl Lee Contact Phone No.: 415-902-5089 Make/Model of Monitoring System: TLS-350 Date of Testing/Servicing: 1/29/2018 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicate specific equipment Inspected/serviced: Tank ID: 8 7 Tank ID: 9 1 In-Tank Gauging Probe. Model: _S 4 7 3 9 0-1 1 1 m In-Tank Gauging Probe. Model: 547390-111 Annular Space or Vault Sensor. Model: 794380-30.3 m Annular Space or Vault Sensor. Model: 794380-303 Piping Sump I Trench Sensor(s) Model: 794-18()-20p m Piping Sump/Trench Sensor(s) Model: 794380-208 v Fill Sump Sensor(s). Model: 794380-209 0 Fill Sump Sensor(s). Model:'7 94 3 8 0-2 C 8 Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: 7 Electronic Line Leak Detector Model: 848480 m Electronic Line Leak Detector Model: $48480 7 Tank Overfill/High-Level Sensor, Model: Vg m Tank Overfill/High-Level Sensor. Model: VR Other(specify equipment and model in Section E on Page 2). ❑ Other(specify equipment and model in Section E on Page 2). Tank ID: nST, Tank ID: In-Tank Gauging Probe, Model: S47390-111 ❑ In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 794380-303 ❑ Annular Space or Vault Sensor. Model: i Piping Sump/Trench Sensor(s). Model: 794380-207 ❑ Piping Sump/Trench Sensor(s). Model: i Fill Sump Sensor(s). Model: 794380-208 ❑ Fill SumpSensogs) Model: Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: V Electronic Line Leak Detector Model: 848480 ❑ Electronic Line Leak Detector Model: i Tank Overfill/High-Level Sensor. Model: VR ❑ Tank Overfill/High-Level Sensor. Model: Other(specify equipment type and model in Section E on Page 2). ❑ Other(sp"equipment type and model in Section Eon Dispenser ID: 1/2 Dispenser ID: 3/4 Dispenser Containment Sensor(s). Model: 794380-208 ❑ Dispenser Containment Sensor(s). Model: 794380-208 Shear Valve(s). m Shear Valve(s). Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: _51 6 Dispenser ID: 7/8 Dispenser Containment Sensor(s). Model: 794380-208 ❑ Dispenser Containment Sensor(s). Madel: 794380-208 Shear Valve(s). 0 Shear Valve(s). Dispenser Containment Floats and Chain(s). 0 Dispenser Containment Floats and Chain(s). DlspenserlD: Dispenser ID: Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ShearValve(s). ❑ ShearValve(s). Dispenser Containment Floats and Chain(s), ❑ Dispenser Containment Floats and Chain(s), If the facility contains more tanks or dispensers,copy this forth Include information 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' checklists) necessary to verify that this Information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generatl such reports, I have also attached a copy of the report;(check all that appty): '0 System set-up Alarm history port Technician Name(print): David Rouse Signature: Certification No.: B44848 License.No.: 220793 Testing Company Name: Gettier-Ryan Inc. Phone No.: 925-551-7555 Testing Company Address: 6805 Sierra Court Suite G.,Dublin CA 94568 Date of Testing/Servicing: 1/29/18 Monitoring System Certification Page 1 of 4 12/07 1