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im61rria-RyAm INc. GR Job# 20-630005 Appendix VI 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 ownerloperator.The ownerloperator 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 SS 2186 Bldg.No.: Site Address: 3212 N.California Street city. Stockton zip: Facility Contact Person: Sarah Samuels Contact Phone No.: 360-371-8111 Make/Model of Monitoring System: VR TLS 35OR Date of Testing/Servicing: 111 312 0 1 5 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicate specific equipment Ins ectedlserviced: i TanklD: 87-1 Master TanklD: 87.2 Siphon D In-Tank Gauging Probe. Model: 847390-109 CO In-Tank Gauging Probe. Model: 847390-109 Annular Space or Vault Sensor. Model: 7S4390409 © Annular Space or Vault Sensor Model: 79439040 W Piping Sump/Trench Sensor(s). Madel: 7943W208 00 Piping Sump/Trench Sensor(s). Model: 794380-208 0 Fill Sump Sensor(s). Model: 794380-208 10 Fill Sump Sensor(s). Model: 794380-208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector Model: © Electronic Line Leak Detector Model: 8484.80 ❑ Electronic Line Leak Detector Model: © Tank Overfill/Hlgh-Level Sensor. Model: VR W Tank Overfill/High-Level Sensor. Model: VR ❑ Other(specify equipment tvpe and model in Section E on Page 21. ❑ Other specify equipment type and model in Section E on Page 2). TanklD: 91-3 TanklD: m In-Tank Gauging Probe Model: 847390-109 ❑ In-Tank Gauging Probe. Model: © Annular Space or Vault Sensor. Model: 794390409 ❑ Annular Space or Vault Sensor. Model: m Piping Sump/Trench Sensor(s). Model: 7 ❑ Piping Sump/Trench Sensor(s). Model: W Fill Sump Sensor(s). Model: 794360-208 ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: (0.7 Electronic Line Leak Detector Model: 848"0 ❑ Electronic Line Leak Detector Model: 0 Tank Overfill/High-Level Sensor. Model: VR 13 Tank Overfill I High-Level Sensor. Model: Other(sped equipment and model in Section E on Page 21. 13 Other(sped equipment type and model in Section E on Page 2). Dispenser ID: 1.2 Dispenser ID: 3.4 W Dispenser Containment Sensor(s). Model: 794380-323 0 Dispenser Containment Sensor(s). Model: 794380.323 W Shearvalve(s). 10 Shear Valve(s). ❑ Dispenser Containment Ffoa s and Chain(s). ❑ Dispenser Containment Ffoa s and Chain(s). Dispenser ID: 5-6 DlspenserlD: 7-8 m Dispenser Containment Sensor(s). Model: 794380-323 W Dispenser Containment Senscr(s). Model: 794380.323 t8 Shear Valve(s). © Shear Valve(s) ❑ Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve($). ❑ Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain(s). .If 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 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 of the report;(check all that apply): p System set-up M Alarm history report Technician Name(print): Chris SanNlcolas Signature: Certification No.: 833787 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: 1113/2015 Monitoring System Certlflcatlon Page 1 of 4 12/07 1