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REGENEU ®6ETTLER-RYAN INC. JUL 13 2018 GR Job# 18201789 Append �iRONMENTX SWRCI3,January 2006 MONITORING SYSTEWMYN d)(1t6N 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, 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 7149 Bldg.No.: Site Address: 9484 West Late City: Stockton Zip 95210 Facility Contact Person: Daryl Lee Contact Phone No.: 415-902-5089 Make/Model of Monitoring System: TLS-350 Date of Testing/Servicing 06/20/2018 B. Inventory of Equipment Tested/Certified Check the appTgrfate boxes to Indicate specific u meat Inspected/serviced: Tank ID: 87 Tank ID: 91 V In-Tank Gauging Probe, Model: 847390-109 m In-Tank Gauging Probe. Model: 847390-109 Annular Space or Vault Sensor. Model: 794390-301 lD Annular Space or Vault Sensor. Model' 794380-301 Piping Sump/Trench Sensor(s) Model: 7 94 3 8 0-2 0 S m Piping Sump/Trench Sensor(s). Model: 7943 8 0-208 V Fill Sump Sensor(s). Model: 0 Fill Sump Sensor(s). Model: Mechanical Line Leak Detector, Model: FE PRTRO m Mechanical Line Leak Detector. Model: LD2 0 0 0 Electronic Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: Tank Overfill/High-Level Sensor. Model: VR FLAPPER m Tank Overfill/High-Level Sensor. Model: VR FLAPPER Other(specify equipment and model in Section E on Page 2). ❑ Other equipment and model in Section E on Page Tank ID: TtST T ank ID: 4 In-Tank Gauging Probe. Model: 847390-109 In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: - Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: - Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: Fill Sump Sensor(s) Model: Mechanical Line Leak Detector, Model: RJ FX1V Mechanical Line Leak Detector. Model: Electronic Line Leak Detector Model: Electronic Line Leak Detector Model: Tank Overfill/High-Level Sensor. Model: VR FLAPPER ❑ Tank Overfill/High-Level Sensor. Model: Other(specify equipment type and model in Section-Eon Page 2). ❑ Other(specify equEment type and model in Section E on Page 2). Dispenser ID: 1-2 Diapenser ID: 3-4 Dispenser Containment Sensor(s). Model: 794-18 0-208 0 Dispenser Containment Sensor(s). Model: 794380--208 Shear Valve(s). m Shear Valve(s). Dispenser Containment Floats and Chain(s). 0 Dispenser Containment Floats and Chain(s). Dispenser ID: 5-6 Dispenser ID: 7-8 i Dispenser Containment Sensors) Model: 794380-208 G3 Dispenser Containment Sensor(s). Model: 794380-208 Shear Valve(s). Shear Valve(s). Dis nser Containment Float(s) and Chair(s). Dispenser Containment Floats and Chain(s). Dispenser ID: 9-10 Dispenser ID: 11-12 Dispenser Containment Sensor(s) Model: 794380-208 0 Dispenser Containment Sensor(s). Model: 794380-208 Shear Valve(s). 0 Shear Valve(s). Dispenser Containment Float(s) 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 - 1 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 verHy at this Information is correct and a Piot Plan showing the layout of monitoring equipment For any equipment ca able of gene ng s reports, 1 have also attached a copy of the report;(check all that apply): 0 System setup 0 Alarm h report Technician Name(print): David Rouse Signature: Certification No.: VR#B44848 ICC#8292530. 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: 06/20/2018 Monitoring System Certification Page 1 of 4 12/07 1