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GETTLER-RYANImc. Appendix V1 ##Job# REC�IVEC MONITORING SYSTEM CERTIFICATION AUG 14 2015 For Use By All Jurisdictions Within the State of Cafitomia Authority Cited:Chapter 6.7, Health and Safety Code, Chapter 16, Division 3, Title 2II 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: Arco 5450 Bldg.No. Site Address: 1617 W Fremont Street —Cily: Stockton Zip: Facility Contact Person: Contact Phone No.: Make/Model of Monitoring System: VR TLS-350 Date of Testing/Servicing: 7/2812015 B. Inventory of Equipment Tested/Certified Check thea boxes to indicate specific!gulpment Insserviced: Tank ID: TI 87-1 Tank ID: T2 87-2 111 In-Tank Gauging Probe. Model: 847390-107 In-Tank Gauging Probe. Model: 846390-107 M Annular Space or Vault Sensor. Model: 794390-4391 D Annular Space or Vault Sensor. Model: 794390.409 W Piping Sump i Trench Sensor(s). Model: 794380-208 13 Piping Sump/Trench Sensor(s). Model: 794380-208 13 Fill Sump Sensor(s). Model: 794-380-344 13 Fill Sump Sensor(s). Model: 794380-344 E3 Mechanical Line Leak Detector. Model: 13 Mechanical Line Leak Detector. Model: 13 Electronic Line Leak Detector Model: 848480 E3 Electronic Line Leak Detector Model: 111 Tank Overfill/High-Level Sensor. Model: C3 Tank Overfill/High-Level Sensor. Model: Overfill Alarm 13 Other(speci!y 2quipment type and model in Section E on Page 2). E3 Other(specify equieMent type and model in Section Eon Pa 2, Tank ID: T3-91 Tank ID: 12 In-Tank Gauging Probe. Model: 8463 E3 In-Tank Gauging Probe. Model: M Annular Space or Vault Sensor. Model: 7 94390-409- Io z 0 Annular Space or Vault Sensor. Model: 13 Piping Sump I Trench Sensor(s). Model: 794380-_208 C3 Piping Sump/Trench Sensor(s). Model: 13 Fill Sump Sensor(s). Model: 79-4390--344 E3 Fill Sump Sensor(s). Model: D Mechanical Line Leak Detector. Model: C3 Mechanical Line Leak Detector. Model: C3 Electronic Line Leak Detector Model: 848480 13 Electronic Line Leak Detector Model: 11 Tank Overfill/High-Level Sensor. Model: Overfill Alarm E3 Tank Overfill/High-Level Sensor. Model: C3 Other LsZa equipment type,and model in Section E on Pa 9j 2). ❑ Others equie=t type and model in Section k2iftat&_ FD—lsp.ser 10: 1-2 Dispenser ID: 3-4 13 Dispenser Containment Sensor(s). Model: 794380-208 13 Dispenser Containment Sensor(s). Model: 794380-208 M Shear Valve(s). ED Shear Valve(s). E3 Dispenser Containment Floats and Chain(s). E3 Dispenser Containment Floats and Chain(s). F—D!ispenser 10: 5-6 DispenserID: 7-8 13 Dispenser Containment Sensor(s). Model: 794380-208 13 Dispenser Containment Sensor(s). Model: 794380-208 13 Shear Valve(s). ED Shear Valve(s). C3 Dispenser Containment Float(s)and ChainW. 13 Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser 10: 0 Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model: 13 Shear Valve(s). C3 shear Valve(s). 13 Dispenser Containment Float(s)and Chains 13 Dispenser Containment Float(s)and Chain(! . -if the facility contains more tanks or dispensers,copy this form.Include information for every tank and dispenser at the facility. C. Certification - I car" 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 Inforrnation 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): 13 System set-up Cip Alarm history revort Technician Name(print): Joey Mesa Signature: K, Certification No.: B33787 License,No.: 220793 Testing Company Name: Gettler-Ryan Inc. Phone No.: 925-561-7555 Testing Company Address: 6805 Sierra Court Suite G Dublin,CA 94568 Date of Testing/Servicing: 7/28/2015 Monitoring System Certification Page I of 4 12f07 I