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Appendix VI - r JUN 01 2016 _a 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 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: Pilot -Flying J #617 Bldg. No.: Site Address: 15100 N. Thornton City: Lodi Zip: 95242 Facility Contact Person: Manager Make/Model of Monitoring System: TLS 350 Contact Phone No.: (_209 ) 339-4066 Date of Testing/Servicing: 0 5/ 0 3/ 2 0 1 6 B. Inventory of Equipment Tested/Certified Check the annronriate boxes to indicate snecifir. enuinment insnarted/sarvicerf- Tank ID: T1 Diesel 20K Tank ID: T2 Diesel 20K C In -Tank Gauging Probe. Model: 846390-109 )U In -Tank Gauging Probe. Model: 846390-109 X] Annular Space or Vault Sensor. _ Model: 794380420 )o Annular Space or Vault Sensor. Model: 794380-420 ❑ Piping Sump / Trench Sensor(s). Model: N/A ❑ Piping Sump/ Trench Sensor(s). Model: N/A ❑ Fill Sump Sensor(s). Model: N/A ❑ Fill Sump Sensor(s). Model: N/A iCI Mechanical Line Leak Detector. Model: VMI LD3000 )CI Mechanical Line Leak Detector. Model: VMI LD3000 ❑ Electronic Line Leak Detector. Model: N/A ❑ Electronic Line Leak Detector. Model: N/A 4 Tank Overfill / High -Level Sensor. Model: 846390-109 TV/Buzzer x❑ Tank Overfill / High -Level Sensor. Model: 846390-109W/Buzzer ❑ Other (seecify equipment t e and model in Section E on Pae 2). ❑ Other(specify equipment t e and model in Section E on Pae 2). Tank ID: T3 Diesel 20K Tank ID: T4 Bio Diesel 20K je In -Tank Gauging Probe. Model: 846390-109 )U In -Tank Gauging Probe. Model: 846390-109 Annular Space or Vault Sensor. Model: 794380-420 M3 Annular Space or Vault Sensor. Model: 794380-420 ❑ Piping Sump/ Trench Sensor(s). Model: N/A ❑ Piping Sump / Trench Sensor(s). Model: N/A ❑ Fill Sump Sensor(s). Model: N/A ❑ Fill Sump Sensor(s). Model: N/A ❑ Mechanical Line Leak Detector. Model: N/A ❑ Mechanical Line Leak Detector. Model: N/A ❑ Electronic Line Leak Detector. Model: N/A ❑ Electronic Line Leak Detector. Model: N/A �j Tank Overfill / High -Level Sensor. Model: 846390-109 w/Buzzer x�] Tank Overfill / High -Level Sensor. Model: 846390-109 W/Buzzer ❑ Other(specify equipment t e and model in Section E on Pae 2). ❑ Other(specify equipment t e and model in Section E on Pae 2). Dispenser ID: 19M Dispenser ID: 19S n Dispenser Containment Sensor(s). Model: 794380-208 n Dispenser Containment Sensor(s). Model: 794380-208 n Shear Valve(s). n Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: 20M Dispenser ID: los )0 Dispenser Containment Sensor(s). Model: 794380-208 C Dispenser Containment Sensor(s). Model: 794380-208 U Shear Valve(s). C Shear Valve(s). ❑ Dis enser Containment Floats and Chain(s). ❑ Dis enser Containment Floats and Chain(s). Dispenser ID: 21M Dispenser ID: 21S r❑ Dispenser Containment Sensor(s). Model: 794380-208 n Dispenser Containment Sensor(s). Model: 794380-208 C Shear Valve(s). n Shear Valve(s). ❑ Dispenser Containment Floats and Chains ❑ 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 verify 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): IT System set-up 10 Alarm history report -dl Technician Name (print): Issac Garcia Signature: Certification No.: B42806 License. No.: 804431 Testing Company Name: Jolles Covey Group, Inc. Phone No.: 88( 8 ) 972-7581 Testing Company Address: 9595 LUCKS Ranch Rd.#100 Rancho Cucamonga CA,91730 Date of Testing/Servicing: 0 5 / 03 / 2 0 1 6 Monitoring System Certification Page of 12/07