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Adh GITFUR-RYAN !ac _ GR Job # 10-062098.1 Appendix VI MONITORING SYSTEMCERTIFICATION For Use By All Jurisdictions Within the State of California Authority Cited. Chapter 6.7, Health and Sathily Code, Chapter 16, Division 3, Title 23, Calffotris 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 ownerloperator. The owner/operator must submit a copy of this form to the local agency relating UST systems within 30 days of test date. A. General Information Facility Name: Arco 2093 Bldg. No.: Site Address: 3425 Tracy Blvd city. Tracy Zip: Fealty Contact Person: Contact Phone No.: Make/Model of Monitoring System: VR TLS350-R Dana of 7estirgrServkkeg: 9/19/2014 B. inventory of Equipment TestedlCertified Check the to Wcale msnt Ins Tank ID: 1.87 Mester Tank ID: 2.87 81ave In-Tank Gauging Probe. Model: 8463WICT ® In-Tank Gauging Probe. Model: "7390.107 ® Anular Space or Vault Seng IN Annular Space or Vault Sensor. Model: NUMM ® Piping Sump / Trends Sensor(s). Modes 11MUM ® Piping Sump t Trends Sensor(s). Model: 790mm ® FBI Sump Sensor(s). Model: 75—WFM ® FD Sump Sensor(s). Mo: Q Mechanical Lire Leak Detector. Q Mechanical Line Leak Detector. 13 Electronic Lia Leak Q Elsetronio Line Leak Detector Model: 13 Tank Overfill / High-Level Sensor. Modet Q Tank Overfill / High-Level Seng. Model: VR Q Doors ul erM MM and model In Section E on Pow 21 Others modal in E 2 10 Tank ID: 3.87 Siphon -and salsee Tank ID: 481 ® In-Tank Gauging Probe. Model: 847 107 IN In-Tank Gauging Probe. Model: 07 ® Annular Space or Vault sensor. Model: 794390409 11 Annular Space or Vault Sensor. Modek 794300400 IN Piping Sump r Trench Sensor(s). Modot 7943M448 IN Pining Sump/ Trench Sensor(s). Model: 7 IN Fill Stag SeaWs). Model: 98 Fig Sump Sensor(s). Model. Rawm Q Mechanical Une Leak Detector. Q Mechanical Une Leak Detector. Q Electronic Une Leak Detector Model. M Electonk Line Leak Detector Rodd: Iwo IN Tank overfill / High-Level Sensor. 10 Tank Overfill / High-Level Sensor. Model: VR Q Dow jjgK&!MuIeMnt WM and morel in Swoon E on Palo 2). Q DOW L52ra MgMit W and model in Section E on Page 2 Dispenser ID: 1-2 DispenserID- 3.4 13 Dispenser Containment Sensor(s). Model; ® Dispenser Containment Sersor(s). Model: 79CM208 10 ShearVatve(s). ® Shear V s). Q ant s arel Cha s Q DWomer ContalnnM nggsjand s. Diapenser 0: 54 Dispenser ID: 7.8 ® Dispenser Containment Sensor(s). ® Dispenser Containment s). Model: 794300- ® Sheer s). to Sherr (s). Q DisgInser Containment QWjsj and C s . Ci Di neer Containment s snd Cha s . Dispensarr Dispenser 10: Q Di C s). Model: Q Dispenser Containment Sensor(s). Q Shear Vaive(s). Q Shear Valve(s). ® R=ser Containment sj and Chat s . 13 Dls nser Conekgrsn4 s and Chat s ' 8 the faciilty, contains more tanks or dbpensers, copy this form. Include information for every tank and dispensw at She facility. C. Certtflcatbn - I certify that the egalpmeM Identified In this document was Inspecteciftervked In accordance with the rta rWtseers° guidelines. Attached to this Cardfication Is kdriumadon (e g. ma ' checklists) nwassM to verify that this Information incorrect and a Plot Plan showing the layout of mardlicring egtdpmerrL For any egcdpment capable of generating such reports, I have also attached a copy of the retort; (cheek all that ® syslant aft-up Q Alarm histery report Technician Nano (print): Chris SanNicoles n Carnftcatim No.: 633787 Lice ss. No.: 220793 Testing company Name: lar Inc. PIS No.: 925.551-7555 Testing Company Address; 0805 Sierra Court Suits G., Dublin, CA 945M Data of Testing/Servk:inli9/19/2014 Morrooring system Csrtticallm Page 1 of 4 12/07