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rw% -% r ri 6ErTLFR-RYAN I,vc. r� Job41 ` —1% "D E v;ve Appendix VI MAR 0 9 2017 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California NN�/�R N TqL EALTH Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 76, Division 3, Title 3 ; �a`/ XrNItIVT 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 6080 Bldg.No.: Site Address: 85 E. Louise Avenue City: Lathrop zip: Facility Contact Person: Daryl Lee Contact Phone No.: 415-902-5089 Make/Model of Monitoring System. TLS-350 Date of Testing/Servicing 2/1/2017 E. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicatespecific equipment Inspected/serviced: Tank ID: 87 Tank ID: 91 ® In-Tank Gauging Probe Model: 547390-111 ® In-Tank Gauging Probe. Model: 547390-111 ® Annular Space or Vault Sensor Model: 794380-303 © Annular Space or Vault Sensor. Model. 794380-303 © Piping Sump I Trench Sensor(s). Model: 794380.208 O Piping Sump/Trench Sensor(s). Model: 794380-208 © Fill Sump Sensor(s). Model: 794380.208 © 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: 8484-80 g Tank Overfill/High-Level Sensor. Model: VR ® Tank Overall/High-Level Sensor. Model: VR ❑ Other(specify equipment type and model in Section E on Page 2. ❑ Other(specify equipment a and model in Section E on Page 2). Tank ID: Diesel Tank ID: ID In-Tank Gauging Probe Model: 547390-111 ❑ In-Tank Gauging Probe Model: ® Annular Space or Vault Sensor. Model: 794380-303 ❑ 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. © Electronic Line Leak Detector Model: 8484-80 ❑ Electronic Line Leak Detector Model: CO Tank Overfill/High-Level Sensor. Model: VR ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment a and model in Section E on-Page 2 ❑ Other(specify equipment a and model in Section E on Page 2). Dispenser ID: 112 Dispenser to: 3/4 © Dispenser Containment Sensor(s). Model: 794380-208 12 Dispenser Containment Sensor(s). Model: 794380-208 ® Shear Valve(s). ID Shear Valve(s). ❑ Dispenser Containment Floats and Chains. ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: 516 Dispenser ID: 7/8 ED Dispenser Containment Sensor(s). Model: 794380-208 ® Dispenser Containment Sensor(s) Model: 794380-208 © Shear Valve(s). 0 Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain(s). EDlspenserID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model. ❑ Shear Valve(s). E3 Shear Valve(s). ❑ 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 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 apply): ® System set-up ® Alarm history report Technician Name(print): Gilbert Garcia Signature Certification No.: 8211864-UT 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: 2/1/2017 Monitoring System Certification Page 1 of 4 12/07 1