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1 GETTLER-RYAN iNC. ob # 20-601659 Appendix VI MONITORINGSYSTEM CERTIFICATION For Use By AM Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California 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: Arco 5450 Bldg. No.: Site Address: 1617 W Fremont City: Stockton Zip: Facility Contact Person: Contact Phone No.: MakelModel of Monitoring System: VT TLS35O-R Date of Testing/Servicing: 8/5/2014 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicate spectfic equipment Inspectediserviced. Tank ID: 1-87 Tank ID: 2.87 ® In -Tank Gauging Probe. Model: 847390-107 ® In -Tank Gauging Probe. Model: 846390-107 ® Annular Space or Vault Sensor. Model: 794390409 12 Annular Space or Vault Sensor. Model: 794390-409 13 Piping Sump / Trench Sensor(s). Model: 794380-208 Q Piping Sump / Trench Sensor(s). Model: 794380.206 ® Fill Sump Sensor(s). Model: 794380-344 IM Fill Sump Sensor(s). Model: 794380-344 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector Model: 8484-80 ❑ Electronic Line Leak Detector Model: ® Tank Overfill / High -Level Sensor. Model: VR ® Tank Overfill / High -Level Sensor. Model: VR ❑ Other (spe2jU equipment tee and model in Section E on Pae 2). ❑ Other (specifX equipment a and model in Section E on Pa2e 2). Tank ID: 3-91 Tank ID: 12 In -Tank Gauging Probe. Model: 846390-107 ❑ In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor, Model: 794396=M ❑ Annular Space or Vault Sensor. Model: ® Piping Sump / Trench Sensor(s). Model: 79M0408 ❑ Piping Sump / Trench Sensor(s). Model: IM Fill Sump Sensor(s). Model: 7 ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. el: ❑ Mechanical Line Leak Detector. el: 13 Electronic Line Leak Detector Model: 0 ❑ Electronic Line Leak Detector Model: IM Tank Overfill / High -Level Sensor. Model: VR ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specft equiement(spec type and model in Section E on Pae 2). ❑ Other (sMa 2quieMent a and model in Section E on Page 2). Dispenser ID: 1-2 Dispenser ID: 3-4 IM Dispenser Containment Sensor(s). Model: 794380-323 IM Dispenser Containment Sensor(s). Model: 794380.323 ® Shear Valve(s). ® Shear Valve(s). ❑ Dise2nser Containment Float(s) and Chain(s). ❑ Dispenser Containment Floor s and Chain(s). Dispenser iD: 0.6 Dispenser ID: 7-8 IM Dispenser Containment Sensor(s). Model: 794380-323 ® Dispenser Containment Sensor(s). Model: 794380-323 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dis enser Containment Floor s and Chain(s). Disperser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Malec: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Fioa s 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 Inspectediserviced 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 stowing 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): p System set-up p Alarm history report Technician Name (print): Chris SanNicolas Signature: 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: 8/5/2014 Monitoring System Certification Page 1 of 4 12/07