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4255517888 Line 1 4:44:43 08-26-2013 Girrw-RYAN INC. GR Job # 20-591947 Appendix V! MONITORING SYSTEM CERTIFICATION For Use By Alf Jurisdictions Within the State of Califomia Authority Cited. Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, Cafifomia Code of Regulations 2114 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: Argo 5450 Bldg. No.: She 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 rhn're fhn n nrinfo 16— Fla in.i4wMn —1R, —.1-- 9.. ...... wr......a....i. Tank ID: T1:87 Main Tank ID: T2: 87 siphon Cal In -Tank Gauging Probe. Model: 847390-107 t:a In -Tank Gauging Probe. Model: 846390-107 Q Annular Space or Vault Sensor. Model: 7 -409 ® Annular Space or Vault Sensor. Model: 794390-409 LE Piping Sump / Trench Sensor(s). Model: 794380-323 ® Piping Sump/ Trench Sensor(s). Model: 794380-344 C2 Fill Sump Sensor(s), Model: 794380344 ® Fill Sump Sensor(s). Model: Cl Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model; ❑ Electronic tine Leak Detector Model ❑ Electronic Line Leak Detector Model: 12 Tank Overfill/ High -Level Sensor. Model: Overfill alarm L3 Tank Overfill I High -Level Sensor. Model: Overfill alarm ❑ Other (specify equipment toe and model in Section E Page 2). ❑ Other (specify equipment and model In Section E on Page 2). TanklD: T3:91 TanklD: ® In -Tank Gauging Probe. Model: 846390.107 ❑ In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 794390.409 ❑ Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Motel; 794380323 ❑ Piping Sump/ Trench Sensor(s). Model: ® Fill Sump Sensoria). Model: 794380-344 ❑ 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: Q Tank Overfill / High -Leve! Sensor. Model: Ne-ifi 1 alarm ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify 2quipment bpe and model in Section E on Page 21.E3 Other (spRa eguipm eM and model in Section E on Page 2). Dispenser to: 1/2 DispenserlD: 3.4 Cxl Dispenser Containment Sensor(s). Model: 794380323 1311 Dispenser Containment Sensor(s). Model: 794380.323 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Floats and Chains . ❑ Dispenser Containment Floats and Chains . Dispenser ID: 5/6 Dispenser ID: 7/8 ® Dispenser Containment Sensor(s). Model: 794380323 lYi Dispenser Containment Sensor(s). Model: 794380-323 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment s and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser 10: Dispenser ID; ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). 13 Shear Valve(s). 13Dis nser Containment Floa s and Chains . ❑ Dis ser Containment Floes and Chain(s). K me raamy comains more tanKs or dispensers, Copy tnis ronn. mciude imormaoon rot every tank and dispenser at the raciiity. 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, I have also attached a copy of the report; (check all that apply): ® System set-up 0 Alarm history report Technician Name (print): Joey Mesa Signature: -- Certification No.: A27796 License. No.: 220793 Testing Company Name: Gettler-Ryan Inc. Phone No.: 925-551-7555 Testing Company Address: 6747 Sierra Court Suite J, Dublin, Ca. 94568 Date of Tesfing/Servicing: 8/22/2013 Monitoring System Certification Page i of 4 12/07 I