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6errtfR4YAN INC. GR Jab # / 8202542 Appendix VI SWRCB , January '.1006 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, 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 lank system ownerloperator. The ownerloperator must submit a copy of this form to the local agency regulating LIST systems within 30 days of test date A . Genera= infonnatcn Facility Name : Arco 2093 Bldg . No : Site Address 3425 Tracy Blvd . city, Tracy zip 95376 Facility Contact Person. Daryl Lee Contact Phone No : 415-902-5089 MakefModel of Monitorrg System: TLS^350 Date of TestingiServicing 8/30/2018 8 , inventory of Equipment TeslediCertified Check the appropriate boxes to indicate specific equipment ins ectediserviced: Tank ID: 87 Tank ID: 87 In•TankGauging Probe Model: 847390 - 107 0 in=Tank Gauging Probe Model : 847390107 Annular Space or Vault Sensor. Model: 794390 " 4Q9 121 Annular Space or Vault Sensor Model: 794390 - 409 Paying Sump I Trench Sensor(s), Model: 7 24 3 8 0 y 2.08 0 Piping Sump I Trench Sensor(s), Model: 794380 - 208 Fill Sump Sensogs), Model 794380 - 2 () S 0 Fel Sump Sensor(s). Model: 7943 8 0 ?. 0 8 Mechanical tine Leak Detector, Model: 13 Mechanical L-ne Leak Detector. Model Electronic Line Leak Detector Model: _ 848480 ❑ Elocironz Line Leak Detector Model: i Tank Overfill i HigNLevei Sensor. Model: VR 0 Tank Overfi t i High =Level Sensor, Model VR rl Other iispec1yr equipment [Me and model in Section E on Page 2 ), ❑ Other (specify equipment t e and model in Section E on Page 2). Tank ID: p7 Tank ID: _91 r m4Tank Gauging Probe. Model: 8 4 7 3 90 - 10 7 0 InJank Gauging Probe, Model 847390 , 107 V Annular Space or Vault Sensor. Model: 794390709 0 Annular Space or Vault Sensor Model 7 9 4 3 9 0 4 0 g v Piping Sump / Trench Sensor(s), Model: 4 - 0 8 _ U Piping Sump I Trench Sensor(s) . Model 794380 - 208 i Fill Sump Sensor(s). Model: 7 9�2 0 8 s Fill Sump Sensor(s) Model 794380 - 2 0 8 Mechanical Line Leak Detector. Modes: ❑ Mechanical Line Leak Detector Model Electronic Line Leak Detector Model: 848480 0 Electronic rLme Leak Detector Model 848480 v Tank Overfill I High-Level Sensor Model: VR 0 Tank Overfill i H'9h•Level Sensor. ModelVR Other (specify equipment 1 and model in Section E on Page 2)v 13 Other (specify equipment 1 e and model In Section Eon Page 2). Dispenser ID : 1 _ 2 Dispenser ID: 3 - 4 r Dispenser Containment Sensor(s). Model* 794 3 80 - 208 ® Dispenser Conlamment Sensor(s). Model 794380 208 i ShearValve(s) E1 ShearVolve( s) Dispenser Containment Ficat s and Chain (s). E3 Dispenser Containment Floats and Chain(s) Dispenser ID: 5 . 6 Dispenser ID: 7 _ 8 Dispenser Containment Sensngs) Model: 794380 - 208 0 Dispenser Conta'nment Sensor(s). Model 794380 - 208 a Shear Valve(s) . © Shear Valve(s) Dispenser Containment Floats and Chain(s). 13 Dispenser Containment Float(s) and Chain (s). Dispenser ID: Dispenser ID: Dispenser Containment Sensor(s), Mudel: 0 Dispenser Containment Sensors) 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 facFly C Certification • I certify that the equipment Identified in this document was Inspectediserviced in accordance with the manufacturers' guldellnes. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verity at this information Is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of gone ng su reports, I have also attached a copy of the report; (check all that apply): System sat-up d Alarm hl t report Technic`an Name (print): David Rouse Signature : Certification No : VR# B44848 ICC#8292530 License. No 220793 Testing Company Name: Gettler-Ryan Inc . PhoneNo. : 925 - 551 - 7555 Testing Company Address 6805 Sierra Court Suite G , Dublin CA q45 (;8 Date of TestinglServcirg: 8/3012019 Monitoring System Certification Page 1 of 4 12,107 ED ECEIr {, SEP 2 4 ?_ 018 ) ENVIRONMENTAL 4EA1 TIS DEPARTMENT