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E T,IETTLER-IRYAN INC. Z=� E MONITORING SYSTEM CERTIFICATION 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, California 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 owner/operator. The owner/operator must submit a copy of this form to the local agency regulating LIST systems within 30 days of test date. A. General Information Facility Name: Arco 5450 Bldg. No.: Site Address: 1617 W Fremont St City: Stockton Zip: Facility Contact Person: Contact Phone No.; Make/Model of Monitoring System: TLS350 Date of Testing/Servicing: 812212013 B. Inventory of Equipment Tested/Certified rhark thA ann—Mato hnxo& M IndIrAte anarifle antdnman# lnanarMdls lrd- Tank ID: T1:87 Main Tank ID: T2, 87 siphon ED In -Tank Gauging Probe. Model: 847390-107 Cil Ir, ,Tank Gauging Probe. Model: 846390-107 108 Annular Space or Vault Sensor. Model: 794390-409 M Annular Space or Vault Sensor. Model: 79-4390-409 Piping Sump I Trench Sensor(s). Model: 794380-325 M Piping Sump / Trench Sensor(s). Model: 794380-344 ill FRI Sump Sensor(s). Model: 7W80-344 13 FRI Sump Sensor(s). Model: C3 Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: E3 Electronic Line Leak Detector Model: 13 Electronic Line Leak Detector Model: [11 Tank Overfill i High -Level Sensor. Model: Overfill a erne 131 Tank Overfill / High -L.1 Sensor. Model: Overfill alarm C3 Others 2quipment type and model in Section E on Page 2). C3 Others equiement to and model in Section E on Page 2)_ Tank 10: T3: 91 Tank 10: 18 In -Tank Gauging Probe. Model: 846390-107 0 In -Tank Gauging Probe. Model: M Annular Space or Vault Sensor. Model: 7943 -40C3 Annular Space or Vault Sensor. Model: M Piping Sump / Trench Sensor(s). Model: ?jM6__323 E3 Piping Sump /Trench Sensor(s). Model: 0 Fill Sump Sensor(s). Model: -7T4-3-8d_—W 13 Fill Sump Sensor(s), Model: E3 Mechanical Line Leak Detector. Model: C3 Mechanical Line Leak Detector. Model: E3 Electronic Line Leak Detector Model: 13 Electronic Line Leak Detector Model: M Tank Overfill I High -Level Sensor. Model: MM11 —ajarm E3 Tank Overfill / High -Level Sensor. Model: 0 ,M!9uiR=t to and model in Section E on Ppaae 2. Other (N-t- 0 Other (spEr& 2quipment type and model in Section E on EM 2). DispenserlD., 1/2 Dispenser ID: 34 0 Dispenser Containment Sensor(s). Model: 794380-323 M Dispenser Containment Sensor(s). Model: 794380-323 0 Shear Valve(s). M Shear Valve(s). 13 Dispenser Containment Float(s) and Chains 1. 1 E3 Dispenser Containment Floats and Chain(!). Dispenser ID: 5/6 Dispenser ID: 718 M Dispenser Containment Sensor(s). Model: 7943804123 M Dispenser Containment Sensor(s). Model: 794380323 M Shear Valve(s). M Shear Valve(s). 13 Dispenser Containment FloatLs) and Chaln(s). E3 Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: C3 Dispenser Containment Sensor(s). Model: C3 Dispenser Containment Sensor(s)- Model: E3 Shear Valve(s). ❑ Shear Valve(s). C3 Dispenser Containment Ft Wts and ChainUs . riser Containment Floats ) and Chain(sJ. - sT me Taoiny comains More WKS or aispensers, copy mis rorm. incivae inFormauon Tor every ianK ane oispenser at me Tacufty. C. Certification - I certify that the equipment Identified In this document was Inspectediserviced 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, I have also attached a copy of the report; (check all that apply): is system set-up, [3 Alarm history report Technician Name (print): Joey Mesa Signature: -------- Certification No.: A27796 License. No.: 220793 Testing Company Name: Getltler-Ryan Inc. Phone No.: 925-551-7555 Testing Company Address: 6747 Sierra Court Suite J, Dublin, Ca. 94568 Date of Testing/Servicing: 8122/2013 Monitoring System Certification Page 1 of 4 12107