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9255517888 Line 1 i GETrLER-RYAN INC. 4:24:36 09-25-2014 2/16 G Job # 10-062F.9 8.1 E:11 11M Appendix V1 ONITORiNG SYSTEM CERTIFICATION SEP 2 5 2014 For Use By All Jurisdictions Within the State of California Authority Cited. Chapter 6.7, Health and Safety Code, Chapter 16, Division 3, Title 23, Cafl#W1Rffl~AL HEALTH Regulations PERMITISERVICES 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 2093 Bldg. No.: Site Address: 3425 Tracy Blvd City: Tracy zip: Facility Contact Person: Contact Phone No.: Make/Model of Monitoring System: VR TLS350-R B. Inventory of Equipment Tested/Certried Cheek fhe annrnnriafe horn. fn nA.,.#. ann-S¢n-....¢.....-- 1- e_-.- Date of Testing/Servicing: 9/19/2014 Tank ID: 1.87 Master Tank ID: 2-87 Slave ® In -Tank Gauging Probe, Model: 846390-107 ® In -Tank Gauging Probe. Model: 847390-107 ® Annular Space or Vault Sensor. Model: 794390-409 ® Annular Space or Vault Sensor. Model: 794390.409 10 Piping Sump / Trench Sensor(s). Model: 794380-208 II Piping Sump / Trench Sensor(s). Model: 794380-208 II Fill Sump Sensor(s). Model: 794380-208 II Fill Sump Sensor(s), Model: 794380-208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: II Electronic Line Leak Detector Model: 8484-80 ❑ Electronic Line Leak Detector Model: II Tank Overfill / High -Level Sensor. Model: VR ® Tank Overfill / High -Level Sensor. Model: VR ❑ Other (specify equipment 4 e and model in Section E on Page 2 1 ❑ Other (specify a ul ment type and model in Section E on Page 2). Tank ID: 3-87 Siphon Tank ID: 4.91 ® In -Tank Gauging Probe. Model: 847390-107 ® In -Tank Gauging Probe. Model: 847390-107 II Annular Space or Vault Sensor. Model: 794390-409 II Annular Space or Vault Sensor. Model: 794390-409 ® Piping Sump /Trench Sensor(s). Model: 794380-208 ® Piping Sump / Trench Sensor(s). Model: 794380-208 II 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: II Electronic Line Leak Detector Model: 8484-80 ® Tank Overfill / High -Level Sensor. Model: VR ® Tank Overfill / High -Level Sensor. Model: VR ❑ Other s eci equipment a and model in Section E on Pacle 2). ❑ Other (specify equipment a and model in Section E on Page 2). Dispenser ID: 1-2 Dispenser ID: 34 ® Dispenser Containment Sensor(s). Model: 794380-208 ® Dispenser Containment Sensor(s). Model: 794380-208 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: 5-6 Dispenser ID: 7-8 Dispenser Containment Sensor(s). Model: 794380-208 ® Dispenser Containment Sensor(s). Model: 794380-208 ® ShearValve(s). II Shear Valve(s). ® Dispenser Containment Floats and Chains . ❑ Dispenser Containment Floa s and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). E3 Shear Valve(s). ❑ Dispenser containment Floats and Chains . ❑ Dispenser Containment Floats and Chains . 1� ¢mo ¢aunty cumains more fanr5 or dispensers, copy oris form. include Intormation 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, 1 have also attached a copy of the report; (check all that apply): ® System set-up II Alarm history report Technician Name (print): Chris SanNicolas Signature: Certification No.: 833787 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: 9/19/2014 Monitoring System Certification Page 1 of 4 1 Received Time Sep, 25. 2014 2:16PM No. 7150 12/07