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im 6fTT1fR-RYAN IXC. iy GR Job# Appendix VI MONITORING SYSTEM CERTIFICATION MAR 2 2010' For Use By All Jurisdictions Within the State of Cafifomia �NI V II H O N M E NTA a Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, Califdfi4 Code CF!'-rR«� 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 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 6080 Bldg No.: Site Address: 85 E Louise Ave city Lathrop zp: Facility Contact Person Contact Phone No.. Make/Model of Monitoring System TLS-350 Date or TestingrServicing: 2!212016 a Inventory of Equipment Tested/Certihed Check the appropriate boxes to Indicate specific 2quipment inspected/serviced: Tank ID: T1 Regular Tank 10: T2 Premium 10 In-Tank Gauging Probe. Model MAG d In-Tank Gauging Probe. Model: MAG [a7 Annular Space or Vault Sensor, Model 794380-303 O Annular Space or Vault Sensor. Model 791380.303 © Piping Sump!Trench Sensor(s). Model: 794380-208!304 © Piping Sump!Trendy Sensor(s) Model: 794S60-208f304 Q Fill Sump Sensor(s). Model. 79438 -2081304 © Fit Sump Sensor(s) Model: 794380-2081304 ❑ Mechanical Line Leak Detector Model. Cl Mechanical Line Leak Detector Model: © Electronic Line Leak Detector Model: 8484.80 D Electronic Line Leak Detector Model 8484-80 cal Tank Overfill/High-Level Sensor Model. VR © Tank Overfill/High-Level Sensor. Model VR ❑ Other s eci a ui ment a and model in Section E on Page 2).. ❑ Others eci a ui ment a and model in Section E on P e 2. Tank ID: T3 Diesel Tank ID: Cil In-Tank Gauging Probe Model: MA ❑ In-Tank Gauging Probe Model D Annular Space or Vault Sensor Model: 794f8-6G7208 ❑ Annular Space or Vault Sensor Model © Piping Sump/Trench Sensor(s), Model: 794180-20MO4 ❑ Piping Sump!Trench Senscr(s) Model: Lit Fill Sump Sensors) Model. 794180.2081304 ❑ Fill Sump Sensor(s). Model. ❑ Mechanical Line Leak Detector. Model ❑ Mechanical Line Leak Detector. Model LD Electronic Line Leak Detector Model 8484-80 ❑ Electronic Line Leak Detector Model: t'sl Tank Overfill 1 High-Level Sensor. Model. VR ❑ Tank Overfill 1 High-Level Sensor. Mode): ❑ Others eci equipment a and model in Section E on Page 2), ❑ Others eci eciumment tvoe and model in Section E on Page 2 Dispenser ID: 1-2 Dispenser ID: 3.4 © Dispenser Containment Sensor(s), Model: 794380-2081304 hd Dispenser Containment Sensogs). Model: 794380.208!304 D Shear Valve(s) Shear Valve(s). ❑ Dispenser Containment Floats and Chains ❑ DJs user Containment Floats and Chain(s). Dispenser 10: 5-6 Dispenser ID: 7-8 Cal Dispenser Containment Sensor(s). Model: 794380-2081304 10 Dispenser Containment Sensor(s) Model: 794380-2081304 EU Shear Valve(s), 10 Shear Valve(s) ❑ Dispenser Containment Float(sj and Chains ❑ 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(s)- ❑ Dispenser Containment I`Wt s and Chains ❑ Dis nser Containment Floats and Chain(s) If the facility contains more tanks or dispensers,oopy 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 whh 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): Q System set-up Cxl Alarm history report Technician Name(print): Tim Adams Signature: Certification No.: B37367 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 TestinglServicirg 2/2/2016 Monitoring System Certification Page 1 of 4 12107 t