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�6imEx-RyA# kc. GR Job# 17204467 Appendix Vi SWRCB,January 2006 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority Cited; Chapter B.7,Health and Safety Code;Chapter 16, Division 3, Title 23, Califomia Code of Regulations This fort 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 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: 95204 Facility Contact Person: Daryl Lee Contact Phone No 415.902.5089 Make/Model of Monitoring System: TLS-350 Date of Testing/Servicing: 1/3/2018 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicate specific equipment Ina tediserviced: Tank ID: 8 7-1 FE3 k ID: 8 7-2 In-Tank Gauging Pmbs. Model: 847390-109 In-Tank Gauging Probe. Model: 847390-109 v Annular Space or Vault Sensor. Model: 794390-40c) Annular Space or Vault Sensor. Model: 7943 9 0-409 V Piping Sump/Trench Sensor(s). Model: 7 94 3 8 0-2 0 8 Piping Sump/Trench Sensor(s). Model:'g r 3 8 0-2 0 8 Fill Sump Sensor(s). Model: 794380-208 Fill Sump Sensor(s). Model:7 94 3 8 0-2 Q'S"8 Mechanical Line Leak Detector. Model. Mechanical Line Leak Detector. Model: Electronic Line Leak Detector Model 848480 Electronic Line Leak Detector Mme: Tank Overfill/High-Level Sensor. Model: VR m Tank Overfill/High-Level Sensor. Model:_VR Other(specify equipment and model in Section E on P22e 2). ❑ Other sui merit type and model in Section E an Pang 2. Tank ID: _9 I Tank ID: i In-Tank Gauging Probe. Model: 847390-109 ❑ In-Tank Gauging Probe. Mom: Annular Space or Vault Sensor. Model; - ❑ Annular Space or Vault Sensor. Model: i Piping Sump/Trench Sensor(s). Model: _ ❑ Piping Sump/Trench Sensor(s). Model; i FRI Sump Sensor(s), Model: 794380-208 ❑ Fill Sump Sensor(s). Mom: Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model; r Electronic Line Leak Detector Model: 848480 ❑ Electronic Line Leak Detector Model: r Tank Overfill/High-Level Sensor. Model: VR ❑ Tank Overfill/High-Level Sensor. Model Others equipment and model in Section E on Pt 2. ❑ Other equipment type and model in Section E on Pa e 2). Dispenser ID: 1/2 Dispenser ID: 3/4 Dispenser Containment Sensor(s). Model: 794380-2080 Dispenser Containment Sensor(s). Model: '794380-208 r Shear Valve(s). G3 Shear Valve(s). Dis neer Containment Floors and Chains. 0 DisE2nser Containment Float(s) and Chain(s). Dispenser ID: 5/6 Dispenser ID: 7/8 Dispenser Containment Sensor(s). Model: 794380-2080 Dispenser Containment Sensor(s). Model: 794380-208 r ShearValve(s). 0 Shear Valve(s). Dispenser Containment Floors and Chain(s). 1112 Dispenser Containment Floors and Chain(s). Dispenser ID: Dispenser iD. Dispenser Containment Sensor(s). Model: 17 Dispenser Containment Sensor(s). Model: Shear Valve(s). 17 Shear Valve(s). Dise2n3er Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chains. 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 inspectedleerviced 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, 1 have also attached a copy of the repos;(check all that appty): ❑� system setup 0 Alarm hl fo — Technician Name(print): Alexander Tate Signature: Certification No.: B42662 License.No.: 220793 Testing Company Name: Getder-Ryan Inc. Phone No.: 925-551-7555 Testing Company Address: 6805 Sierra Court Suite G.,Dublin CA 94568 Date of Testing/Servicing: 1/3/2018 Monitoring System Certification Page t of 4 12107 1