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Appendix VI JUN 01 2016 <br />MONITORING SYSTEM CERTIFICATION r + �►,a.�.�so� <br />For Use By All Jurisdictions Within the State of California <br />Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of <br />Regulations <br />This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for <br />each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system <br />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. <br />A. General Information <br />Facility Name: Pilot -Flying J #617 Bldg. No.: <br />Site Address: 15100 N. Thornton <br />Facility Contact Person: Manager <br />City: Lodi Zip: 95242 <br />Contact Phone No.: ( 209 339-4066 <br />Make/Model of Monitoring System: TLS 350 Date of Testing/Servicing: 0 5 / 03 / 2 0 1 6 <br />B. Inventory of Equipment Tested/Certified <br />rherk the annronrintp hnrps to indiratp snprifir enuinmpnt insnertPd/sprvir.Pdc <br />TanklD: <br />TanklD: <br />❑ <br />In -Tank Gauging Probe. <br />_ <br />Model: _ <br />❑ <br />In -Tank Gauging Probe. <br />Model: <br />❑ <br />Annular Space or Vault Sensor. <br />Model: <br />❑ <br />Annular Space or Vault Sensor. <br />Model: <br />❑ <br />Piping Sump / Trench Sensor(s). <br />Model: <br />❑ <br />Piping Sump / Trench Sensor(s). <br />Model: <br />❑ <br />Fill Sump Sensor(s). <br />Model: <br />❑ <br />Fill Sump Sensor(s). <br />Model: <br />❑ <br />Mechanical Line Leak Detector. <br />Model: <br />❑ <br />Mechanical Line Leak Detector. <br />Model: <br />❑ <br />Electronic Line Leak Detector. <br />Model: <br />❑ <br />Electronic Line Leak Detector. <br />Model: <br />❑ <br />Tank Overfill / High -Level Sensor. <br />Model: <br />❑ <br />Tank Overfill / High -Level Sensor. <br />Model: _ <br />❑ <br />Other(specify equipment t e and model <br />in Section E on Pae 2). <br />❑ <br />Other(specify equipment t e and model <br />in Section E on Page 2). <br />Tank ID: <br />Tank ID: <br />❑ <br />In -Tank Gauging Probe. <br />Model: <br />❑ <br />In -Tank Gauging Probe. <br />Model: <br />❑ <br />Annular Space or Vault Sensor. <br />Model: <br />❑ <br />Annular Space or Vault Sensor. <br />Model: <br />❑ <br />Piping Sump / Trench Sensor(s). <br />Model: <br />❑ <br />Piping Sump / Trench Sensor(s). <br />Model: <br />❑ <br />Fill Sump Sensor(s). <br />Model: <br />❑ <br />Fill Sump Sensor(s). <br />Model: <br />❑ <br />Mechanical Line Leak Detector. <br />Model: <br />❑ <br />Mechanical Line Leak Detector. <br />Model: <br />❑ <br />Electronic Line Leak Detector. <br />Model: <br />❑ <br />Electronic Line Leak Detector. <br />Model: <br />❑ <br />Tank Overfill / High -Level Sensor. <br />Model: <br />❑ <br />Tank Overfill / High -Level Sensor. <br />Model: <br />❑ <br />Others ecif e ui ment type and model <br />in Section E on Pae 2). <br />❑ <br />Other (s2ecify equipment t e and model <br />in Section E on Pae 2). <br />Dispenser ID: 28M <br />Dispenser ID: les <br />)El <br />Dispenser Containment Sensor(s). <br />Model: 794380-208 <br />Ti <br />Dispenser Containment Sensor(s). <br />Model: 794380-208 <br />C <br />Shear Valve(s). <br />C <br />Shear Valve(s). <br />❑ <br />Dispenser Containment Floats and <br />Chain(s). <br />❑ <br />Dis enser Containment Floats and <br />Chain(s). <br />Dispenser ID: 29M <br />Dispenser <br />ID: 29S <br />• <br />Dispenser Containment Sensor(s). <br />Model: 794380-209 <br />C <br />Dispenser Containment Sensor(s). <br />Model: 794380.208 <br />• <br />Shear Valve(s). <br />C <br />Shear Valve(s). <br />❑ <br />Dispenser Containment Float(s) and <br />Chain(s). <br />❑ <br />Dispenser Containment Float(s) and <br />Chain(s). <br />DispenserlD: 30M <br />Dispenser ID: 30S <br />)EI <br />Dispenser Containment Sensor(s). <br />Model: 794380-208 <br />C <br />Dispenser Containment Sensor(s). <br />Model: 794380-208 <br />+D <br />Shear Valve(s). <br />C <br />Shear Valve(s). <br />❑ Dispenser Containment Floats and Chains <br />❑ <br />Dispenser Containment Floats and Chain(s). <br />`If the facility contains more tanks or dispensers, copy this form. Include intormation for every tank and dispenser at the facility. <br />C. Certification - I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' <br />guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct <br />and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a <br />copy of the report; (check all that apply): gl System set-up 91 Alarm history report <br />Issac Garcia <br />Technician Name (print): Signature: <br />Certification No.: 842806 License. No.: 804431 <br />Testing Company Name: Jones Covey Group, Inc. Phone No.: 88( 8 ) 972-7581 <br />Testing Company Address: 9595 Lucas Ranch Rd.#100 Rancho Cucamonga CA, 91730 Date of Testing/Servicing: 0 5 / 03 / 2 0 1 6 <br />Monitoring System Certification Page of 12/07 <br />