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GuriER-RYAN INt. Job# RE62 ;+VE1) Appendix Vf AUG 12 2015 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, QBlitomiarlMade'of-m-T 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 City: Stockton Zip: Facility Contact Person: Contact Phone No.: Make/Model of Monitoring System: VR TLS-350 Date of Testing/Servicing: 7/28/2015 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicate specific equipment Inspected/serviced: Tank ID: T1 87-1 Tank ID: T2 87-2 ® In-Tank Gauging Probe. Model: 847390-107 ® In-Tank Gauging Probe. Model: 846390-107 © Annular Space or Vault Sensor. Model: 794390-409 © Annular Space or Vault Sensor. Model: 794390409 © Piping Sump/Trench Sensor(s). Model: 794380-208 D Piping Sump/Trench Sensor(s). Model: 794380-208 Fit Sump Sensor(s). Model: 794380-344 Fill Sump Sensor(s). Model: 794380-344 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Madel: m EkwAronic Line Leak Detector Model: 848480 ❑ ElecWnic Line Leak Detedor Model: m Tank Overfill/High-Level Sensor. Model: Overfill Alarm ® Tank Overfill/High-Level Sensor. Model: Overfill Alarm ❑ Other equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). Tank 10: T3-91 Tank 10: ® In-Tank Gauging Probe. Model: 846390-107 ❑ In-Tank Gauging Probe. Model: IN Annular Space or Vault Sensor. Model: 794390-409 ❑ Annular Space or Vault Sensor. Model: 13 Piping Sump/Trench Sensor(s). Model: 794380-208 ❑ Piping Sump/Trench Sensor(s). Model: 13 Fill Sump Sensor(s). Model: 380-344 ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: 12 Electronic Line Leak Detector Model: 848480 ❑ Electronic Line Leak Detector Model: IX Tank Overfill/High-Level Sensor. Model: Overfill Alarm ❑ Tank Overfil/High-Level Sensor. Model: ❑ Other equipment type and model in Section E on Pa e 2). ❑ Other(specify equipment type and model in Section E on Pa e 2. Dispenser ID: 1-2 Dispenser ID: 34 Cal Dispenser Containment Sensor(s). Model: 794380-208 ® Dispenser Containment Sensor(s). Model: 794380-208 M Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain(s). Dispenser ID- 5 6 DispenserlD: 7-8 ® Dispenser Containment Sensor(s). Model: 794380-208 ® Dispenser Containment Sensor(s). Model: 794380-208 © Shear Valve(s). CO Shear Valve(s). ❑ Dispenser Containment Flocs and Chain(s). ❑ Dispenser Containment Floats and Chain(s). Dispenser 10: DlspenserlD: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain(s). •If the facility contains more tanks or dispensers,copy this form.Include 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 verity 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): M System set-up a] Alarm history report Technician Name(print): Joey Mesa Signature: i Certification No. 833787 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: 7/28/2015 Monitoring System Certification Page 1 of 4 12/07 1