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92517888 Line 1 im GirTUR-RYAN INC. 14:52:55 09-11-2014 2/4 Job # 20-602042 Appendix VI RECEIVED MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of"California SEP 112014 Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations ENVIRONMENTAL LT This form must be used to document testing and servicing of monitoring equipment. A separate certification or ror each monitoring system control panel by the technician who performs the work. A copy of this form must be provi ed tote n sem 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: Kaiser Bldg. No.: Site Address: 1777 W Yosemite Ave City: Manteca zip: Facility Contact Person: Contact Phone No.: Make/Model of Monitoring System: TRS 350 Date of Testing/Servicing: 8/29/2014 B. Inventory of Equipment Tested/Certifled Cheri.& n,. i. .. *n 1";,� —..ta...,..s........... a...-.-__a_�r___� Tank ID: T-1 AST Diesel Tank ID: T-2 UST Diesel ❑ In -Tank Gauging Probe. Model: ® In -Tank Gauging Probe, Model: MAG IM Annular Space or Vault Sensor. Model: 794390.420 IM Annular Space or Vault Sensor. Model: 794360.303 IM Piping Sump / Trench Sensor(s), Motel: 794380.206 M Piping Sump / Trench Sensor(s). Model: 794380 -208 --- IM FNI Sump Sensor(s). Model: 794360-206 ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector Model: ❑ Electronic line Leak Detector Model: ® Tank Overfill / High -Levet Sensor. Model: Flapper ❑ Tank overfill / High -Level Sensor. Model: ❑Other (specify equipmerd type and model in Section E on Page 2)1. ❑ Other (see& 2quipment type and model in Section E on e 21 TankID: Tank ID: ❑ in -Tank Gauging Probe. Model: ❑ in -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/ Trench Sensor(s). Model: 13 Piping Sump / Trench Sensor(s), Model: E3 Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(&). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line teak Detector Model ❑ Electronic Line Leak Detector Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill I High -Level Sensor. Model: ❑ Others c ui eM a and model in Section E on Page 2). ❑ Other (specyy 2guipment(spec Me and model in Section E on Page 21 Dispenser 10: Dispenser ❑ Dispenser Containment Sensor(s). Model: nser Containment Sensor(s). Moles: ❑ Shear Valve(s). Valve(s). ❑ Dis riser Containment Floa s and Chai s . user Containment Flo s and Chains . Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Senors). Model: ❑ Shear Valve(s). O Shear Valve(s). ❑ Di ser Containment Float(s) and Chain(s). ❑ Dispenser Containment Floa s and Cha? s DispenserlD-, DispenserlD: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Disp2nsar Containment Floa s and Chai s . ❑ Dispenser Containment Fba s and Chain(s). I. — 1-1.1, ui a�apergms, way oris norm. moivae hmormauon ror every tanx aro oispenser at the tacany. 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 ® Alarm history report Technician Name (print): Tim Adams Signature: _ - „4�� 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 Testing/Servicing: 8/29/2014 Monitoring System Certification Page 1 of 4 12107 I