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VfTTtFR-RrAN /Nc. RECEIVELVp GR Job# 17204467 JAI 1Appendix VI SWRCB,January 2006 MQ�IIT i �- TNI; CERTIFICATION F Se �ii[rs;ti� pns, thin the State of Califomia Authority Cited. Chapter 6.7,Heal ja i 5'afefy bode; 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 LIST 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 spectfic equipment Ins d/servicPad: Tank ID: 87-1 Tank ID: 8 7-2 i In-Tank Gauging Probe. Model: 847390-109 m In-Tank Gauging Probe. Model: 847390-10 Annular Space or Vault Sensor, Model: 794390-409 m Annular Space or Vault Sensor. Model: 794390-409 i Piping Sump/Trench Sensor(s). Model: 794380-208 m Piping Sump/Trench Sensor(s). Model: 7,94380-208 Fill SumpSensor(s). Model: 794380-208 m Fill Sump Sensor(s). Model: 794380-208 Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: i Electronic Line Leak Detector Model: 848480 ❑ Electronic Line Leak Detector Model: Tank Overfill/High-Level Sensor. Model: Vg m Tank Overfill/High-Level Sensor. Model: VR Other(specify equipment and model in Section E on Pane 2). ❑ Other(specify equiement and model in Section E on Pag6 2). Tank ID: 91 Tank ID: In-Tank Gauging Probe, Model: 847390-109 ❑ In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: - ❑ Annular Space or Vault Sensor. Modei i Piping Sump/Trench Sensor(s). Model: - ❑ Piping Sump/Trench Sensor(s). Model. Fill Sump Sensor(s). Model: 794.380-208 ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: i Electronic Line Leak Detector Model: 848480 ❑ Electronic Line Leak Detector Model Tank Overfill/High-Level Sensor. Model: VR ❑ Tank Overfill/High-Level Sensor. Model- Other(s odel:Others ui ment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). Dispenser ID: 1/2 EDispenser ser ID: 3/4 i Dispenser Containment Sensor(s). Model: 794380-208Dispenser Containment Sensor(s). Model: 794380-208 Shear Valve(s). Shear Valve(s). Dispenser Containment Floats and Chains. Containment Floats and Chain(s). Dispenser ID: 5/6 Dispenser ID: 7/8 i Dispenser Containment Sensor(s). Model: 7 94 3 8 0-2 0 8 U3 Dispenser Containment Sensor(s). Model: 794380"-208 Shear Valve(s). Shear Valve(s). Dispenser Containment Floats and Chain(s). 0 Dispenser Containment Floats and Chain(s). Dispenser ID: Dispenser ID: Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model: Shear Valve(s). 0 Shear Valve(s). Dise2nser 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 Piot 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): system set-up 0 Alarm his)ory Technician Name(print): Alexander Tate Signature: �- Certification No.: B42662 License.No.: 220793 Testing Company Name: Gettler-Ryan Inc. Phone No.: 925-551-7555 Testing Company Address: 6805 Sle1Ta Court Suite G.,Dublin CA 94568 Date of Testing/Servicing: 13/2018 Monitoring System Certification Page 1 of 4 12/07 I