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9255517888 Line 1:14:52 11-18-2013 2/17 WErna-RYAN INC. G ob # R606EIVED Appendix VI NOV 18 2013 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the Stats of Cal/fornia ENVIRONMENTAL Authority Cited. Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, Califo i 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: ACCO 2093 Bldg. No.: Site Address: 3425 Tracy Blvd City. Tracy zip: Facility Contact Person: lgbal S. Baing Contact Phone No.: 209-835-1605 Make/Model of Monitoring System: VR TLS 35OR Date of Testing/Servicing: 11/14/2013 B. Inventory of Equipment Tested/CerMed Tank ID.- 1-87 Tank 10: 2-87 M ® In -Tank Gauging Probe, Model: 847390-107 M In -Tank Gauging Probe. Model; 846390.107 Annular Space or Vault Sensor. Model: 794390.409 M Annular Space or Vault Sensor. Model: 79439M9 ® Piping Sump /Trench Sensor(s). Model: 79W80-323 M Piping Sump / Trench Sensor(s). Model: 7WOOM M ❑ Fill Sump Sensor(s). Model: 794380-323 M Fill Sump Sensor(s), Model: $0.32 Mechanical Line Leak Detector. Model: ❑ Mechanical Lina Leak Detector. Model: ❑ Electronic Line Leak Detector Model: J M Electronic Line Leak Detector Model; 0 M Tank Overfill / High -Level Sensor. Modet VR M Tank Overfill i High -Level Sensor. Model: VR ❑ Other ispectl5v equigMent and model In Section E on Pa e 2). ❑ Other c1N equipment Woe and model in Section E on Pae 2 . Tank iD: 3487 Tank ID: 4-91 ® ® In -Tank Gauging Probe. Model: 847390-107 M In -Tank Gauging Probe. ModeC 847390-107 Annular Space or Vault Sensor. Model: 794390-409- M Annular Space or Vault Sensor. Madel: 79439 09 M Piping Sump / Trench Senaor(s). Model; 79438 M Piping Sump /Trench Senscr(s). Model: 79 03 M ❑ Fill Sump Sensor(s). Model: 794380-325 M Fill Sump Sensor(s). Model: 79438"3 3 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Una Leak Detector. Model: Electronic Line Leak Detector Model: M Electronic Line Leak Detector Madel; 8 M Tank Overfill / High -Level Sensor, Model: V M Tank Overfill / High -Level Sensor. Model: VR ❑ Other (sPecifv a ui ent type and model in Sectio; -E- on Page 21 ❑ Other (specify eqv!eMnt!ae and model in Section E on e 2 . Dispenser ID: 112 Dispenser ID: 3.4 M Dispenser Containment Sensor(s). Model: 794380.323 M Dispenser Containment Sensor(s). Model: 794380.323 M Shear Valve(s). M Shear Valve(s). ❑ Dis ser Containment Floa s and Chains . ❑ Dispenser Containment Floa s and Chain(s). Dispenser iD: 5-6 Dispenser ID: 7-8 M Dispenser Containment Sensor(s). Model: 794380-323 ® Dispenser Containment Sensor(s), Model: 794380323 M Shear Valve(s). M Shear Valve(s). ❑ Ols22nser Containment Flpat s and Chad s . ❑ Dis eraser Containment Fls and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Vaive(s). ❑ Shear Valve(s). ❑ Dls nser Containment 5otLal and ChaifXsl ❑ Dis nser Containment Floa s and Chai s . u..m.J w. non w uRA6 -,.N* W UISpCIhlCi3, copy snag rorm. mcruae imormation ror every tank and dispenser at the facility. C. Certification - i certify that tate equipment Identified In this document was Inspectedlserviced 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.i?)aa stti Wrtg.lhe laj=.of mani -equipmea Far..any.equipmentcapable of.geneaatlgg--such-wports,-/-have-also attached -s- —. copy of the report, (check ail that apply): M System set-up M Alarm historX report_ �A Technician Name (printr Chris SanNicolas Signature: Certification No.: B33787 License. No.: 220793 Testing Company Name: ('settler -Ryan Inc. Phone No.: 925-551-7555 Testing Company Address: 6747 Sierra Court Suite J, Dublin, Ca. 94568 Date of Testing/Servicing: 11/1412013 Monitoring System Certification Page 1 of 4 12107 1