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'i GETTtER-RyAm hic. GR Job 172025 $ Appendix VI tJ MONITORING T 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 2,3,Califvmia 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 Street city: Stockton zip: 95203 Facility Contact Person: Darty Lee Contact Phone No.: 415.902.5089 Make/Model of Monitoring System: TLS 350 R Date of Testing/Servicing: 7/20/2017 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicates ific e u merit Ins serviced: Tank 10: 87 Tank ID: 87 IS In-Tank Gauging Prole. Model: 846390-107 C1 in-Tank Gauging Probe. Model: 846390-107 iX Annular Space or Vault Sensor. Model: 794390-409 Ig Annular Space or Vault Sensor. Model: 794390.409 IX Piping Sump/Trench Sensor(s). Model: 794380-208 I$ Piping Sump/Trench Sensor(s). Model: 794380-208 IS Fill Sump Sensor(s). Model: 794380-344 iZ Fill Sump Sensor(s). Model: 794380-344 ❑ Mechanical Line Leak Detector, Model: ❑ Mechanical Line Leak Detector. Model: CK Electronic Line Leak Detector Model: 8484-80 ❑ Electronic Line Leak Detector Model: Ig Tank Overfill/High-level Sensor. Model: VR I$ Tank Overfill/High-Level Sensor. Model: VR ❑ Others ui ment type and model in Section E on P e 2). ❑ Other(set&a u' ment type and model in Section E on Pae 2). Tank ID: 91 Tank ID: IX in-Tank Gauging Probe. Model: 846390-107 ❑ In-Tank Gauging Probe. Model: IS Annular Space or Vault Sensor. Model: 794390-409 ❑ Annular Space or Vault Sensor. Model: DI Piping Sump/Trench Sensor(s). Model: 794380-208 ❑ Piping Sump/Trench Sensor(s). Model: M Fill Sump Senors). Model: 794380-34413 FIII Sump Sensors). Model: ❑ Mechanical tine Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: I% Electronic Line Leak Detector Model; u4no ❑ Electronic Line Leak Detector Model: IX Tank Overfill/High-Level Sensor. Model: VR ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment and model in Section E on Pae 2. 13 Other s ui merit type and model in Section E on Pae 2). Dispenser ID: 1/2 Dispenser ID: 3!4 DL Dispenser Containment Sensor(s). Model: 794380-208 I$ Dispenser Containment Senors). Model: 794380-208 (g Shear Valve(s). IS Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: 616 Dispenser ID: 718 IX Dispenser Containment Sensor(s). Model: 794380-208 I$ Dispenser Containment Sensor(s). Model: 794380-208 iZ Shear Valve(s). I$ Shear Valve(s). ❑ Dis user Containment Floats and Chain(s). ❑ Dis user Containment Floats and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Di enser Containment Float(sj and Chains. If the facility contains more tanks or dispensers,copy this form.Ind de information for every tank and dispenser at the facility. 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 i2 Alarm history report Technician Name(print): Gilbert Garcia Signature: Certification No.: 8211864-UT 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: 7/20/2017 Monitoring System Certification Page 1 of 4 12/07 1