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®&TTLER-9YAN INC. GR Job# 17204467 Appendix VI SWRCB,January 2006 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of Califomia 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. Califomia City: Stockton Zip: 95204 Facility Contact Person: Daryl Lee Contact Phone No.: 415.902.5089 Maka/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 2quipment Ina tedlserviced: Tank ID: 87-1 Tank ID: 87-2 In-Tank Gauging Probe. Model: 847390-109 m Irl-Tank Gauging Probe. Model: 847390-Ing Annular Space or Vault Sensor. Model: 7 94 3 9 0-4 0 m Annular Space or Vault Sensor. Model: — —� 194Piping Sump/Trench Sensar(s). Model: 794380-20$ m Piping Sump!Trench Sensor(s). Madel:l8Fill SumpSensor(s). Model: 794380-208 m Fill SumpSensor(a). Model: 794380-2Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: Electronic Line Leak Detector Model: 848480 ❑ Electronic Line Leak Detector Model: Tank Overfill/High-Level Sensor. Model: VR @ Tank Overfill/High-Level Sensor. Model. VR Others a ui ment and model in Section E on P e 2. ❑ Others ui ment and model in Section E oh Pa 6"2 TanklD: 9 1 TanklD: In-Tank Gauging Probe. Model: 847390-109 ❑ In-Tank Gauging Probe. Model: 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: Fill Sump Sensogs). Model: 794T8_07208 ❑ 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: Others equipment and model in Section E on Pape 2). ❑ Others equipment and model in Section E on Pa e 2). Dispenser ID: 1/2 Dispenser ID: 3/4 Dispenser Containment Sensor(s). Model: 794380-208 ❑ Dispenser Containment Sensor(s) Model: 794380-208 i Shear Valve(s). G3 Shear Valve(s). Dispenser Containment FI s and Chain(s) ❑ Dispenser Containment Floa s and Chain(s). Dlepenser ID: 5/6 [DlapensorID: 7/8 Dispenser Containment Sensor(s). Model: 794380-208 Dispenser Containment Sensors). Model: 794380-208 Shear Valve(s). Shear Valve(s). Dis nser Containment Floa s and Chains. Dis nser Containment Float(s)and Chain(s). DispenserlD: Dispenser 10: Dispenser Containment Sensor(s). Moder: ❑ Dispenser Containment Sensors), Model: Shear Valve(s). ❑ Shear Valve(s). Dispenser Containment Float(s) and Chains. ❑ 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): [Z] System set-up Q Alarm h� �` _ Technician Name(print): Alexander Tato Signature: Certification No.: B42662 License.No.: 220793 Testing Company Name: Gettler-Ryan Inc. Phone No.: 925-551-7555 Testing Company Address: 6806 Sierra Court Suite G.,Dublin CA 94568 Date of Testing/Servicing: 1/3/2018 Monitoring System Certification Page 1 of 4 12/07 1