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Gf r rL it - RYAN INC. GR •• # 20-591947 Appendix VI MONITORING SYSTEM IFI TI For Use By A# Jurisdictions Within the State of California Authority Cited. Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, Califomia 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 UST systems within 30 days of test date. A. General Information Facility Name: ACCO 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: 8/22/2013 B. Inventory of Equipment Tested/Certified Check the anmmnriata hnrea fn Indiraf® -/fir nn,rlmm.M h..:..a..a�i.s...r..ea. Tank to: T1:87 Main Tank ID: T2: 87 siphon ® In -Tank Gauging Probe. Model: 847390-107 ® In -Tank Gauging Prof. Model: 846390-107 ® Annular Space or Vault Sensor. Model: 794390409 ® Annular Space or Vault Sensor. Model: 794390409 13 Piping Sump / Trench Sensor(s)- Model: 794380-323 (S Piping Sump / Trench Sensor(s). Model: 794380444 ® Fill Sump Sensor(s). MSI: 94380-344 ® 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: ® Tank Overfill / High -Level Sensor. Model: Overfill alarm 12 Tank Overfill / High -Level Sensor. Model: Ove Ila arm ❑ Others cjfy 2guiement!yEe and model in Section E on Page 2). ❑ Others a ui ment and model in Section E on Pa e 2). Tank ID: T3:91 Tank ID: ® In -Tank Gauging Probe. Model: 846390-107 ❑ in -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 7943 -40 ❑ Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Modet 794380-323 ❑ Piping Sump/ Trench Sensor(s). Model: Fill Sump Sensor(s). el: 794380- Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: U Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: M Tank Overfill / High -Level Sensor. Model: -Nail alarm ❑ Tank Overfill / High -Level Sensor. Model: ® Others ui ment and model in Section E on Pa e 2 . E3 Other ui men4 and model in Section E on Page 2)._ Dispenser to* 1/2 Dispenser ID: 3-4 ® Dispenser Containment Sensor(s). Madel: 794380-323 M Dispenser Containment Sensor(s). Model: 794380323 ® Shear Valve(s). M Shear Valve(s). ❑ Dispenser Containment Float(s) and Chains . ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5/6 Dispenser ID: 7/8 ® Dispenser Containment Sensor(s). Model: 794380323 13 Dispenser Containment Sensor(s). Model: 794380-323 ® Shear Valve(s). ® Shear Valve(s). ® Dispenser Containment Float(s) and Chains . ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: DlspenserlD: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ® Dise2nser Containment Floats and Chains . ❑ Dispenser Containment Floats and Chain(s). n we racuny t vmama more tanrs or arspensers, copy mis Torm. mcivae Rnomeation for every tank and dispenser at the facility. C. Certification - I certify that the equipment Identifled In this document was inspected/servlced 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 ID 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 Testing/Servicing: 8/22/2013 Monitoring System Certification Page 1 of 4 12/07 U