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, &TTIFURYAN INC. GR Job# W*040 Appendix VI JAN 2 2 2016 MONITORING SYSTEM CERTIFICATION ENVIRON'WENTALHEALTH For Use By All Jurisdictions Within the State of Califomia FERMI TISERVICES 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 2186 Bldg.No.: Site Address: 3212 N California City: Stockton zip: Facility Contact Person: Contact Phone No.: Make/Model of Monitoring System: TLS 350 Date of Testing/Servicing: 117/2016 B. Inventory of Equipment Tested/Certified Check the appropriate taxes to Indicatespecific uI nt inspected/serviced: Tank ID: T-1 Master Tank ID: T-2 Siphon m In-Tank Gauging Probe. Model: 847390-109 © in-Tank Gauging Probe. Model: 847390-109 E3 Annular Space or Vault Sensor. Model: 7W3WM9 Annular Space or Vault Sensor. Model: 7943 0.409 © Piping Sump/Trench Sensor(s). Model: 794380.208 © Piping Sump/Trench Sensor(s). Model: 943 0. 08 © Fill Sump Sensor(s). Model: 794380-208 © Fill Sump Sensor(s). Model: 94380-208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: M Electronic Line Leak Detector Model: 8484$0 ❑ Electronic Line Leak Detector Model: IM Tank Overfill/High-Level Sensor. Model: VR © Tank Overfill/High-Level Sensor. Model: VR ❑ Other equipment type and model in Section E on Eacle 2. ❑ Other s ei equipment type and model in Section E Page 21. Tank ID: T-3 91 Tank ID: M In-Tank Gauging Probe. Model: 847390-109 ❑ In-Tank Gauging Probe. Model: m Annular Space or Vault Sensor. Model: 794390-409 ❑ Annular Space or Vault Sensor. Model: © Piping Sump/Trench Sensor(s). Model: 794380-208 ❑ Piping Sump/Trench Sensor(s). Model. © Fill Sump Sensor(s). Model: 794380-208 ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: CO Electronic Line Leak Detector Model: 8484-80 ❑ Electronic Line Leak Detector Model: 13 Tank Overfill/High-Level Sensor. Model: VR ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Pane 2 11 ❑ Other(specify equigment type and model in Section E on Page 2). Dispenser ID: 1.2 Dispenser ID: 3-4 © Dispenser Containment Sensor(s). Model: 794380-323 Dispenser Containment Sensor(s). Model: 794380-323 © Shear Valve(s). © Shear Valve(s). ❑ Dispenser Containment Floal s and Chain(s). ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: S fi Dispenser ID: 7.8 Dispenser Containment Sensor(s). Model: 794380-323 © Dispenser Containment Sensor(s). Model: 794380-323 © Shear Vatve(s). O Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: DispenserlD: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dise2nser Containment Floats and Chain(s). ❑ Dispenser Containment Floal s and Chain(s). H the facility contains more tanks or dispensers,copy this form.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 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 appy): m System set-up ® Alarm history report Technician Name(print): Tim Adams Signature: Certification No.: B37367 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 Date of Testing/Servicing: 11712016 Monitoring System Certification Page 1 of 4 12107 1