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Appendix VI JUN 01 2017 MONITORING SYSTEM CERTIFICATIOrtNVIRONmENTAL HEALTH For Use By Alt Jurisdictions Within the State of Califomia r, 7 T) A Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, Caftrha NAW 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 worts. 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 LIST systems within 30 days of test date. A. General Information Flying J #617 Facility Name: y g Bldg. No.: Site Address: 151000 N. Thornton Rd. City. Lodi, CA. zjp: 95242 Facility Contact Person: Manager Make/Model of Monitoring System: TLS 350 Diesel AST Contact Phone No.: ( 209 ) 339-4066 Date of Testing/Servicing: 0 5/ 02 / 2 0 1 7 B. Inventory of Equipment Tested/Certified Check the annronriate hetes to indicate snacific anuinmant In_¢ner-tPd/carvicari Tank ID: T1 Diesel #2 20k Tank ID: T2 Diesel #2 20k >C In -Tank Gauging Probe. Model: 1146390-109 C In -Tank Gauging Probe. Model: 846390-109 IC Annular Space or Vault Sensor. Model: 794380420 7C Annular Space or Vault Sensor. Model: 794380-420 ❑ Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: )C Mechanical Line Leak Detector. Model: VMl 99 LD3000 u7 Mechanical Line Leak Detector. Model: vMl 99 LD3000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: A] Tank Overfill / High -Level Sensor. Model: 846390-109 w/ Buzzer y7 Tank Overfill / High -Level Sensor. Model: 846390-109 w/ Buzzer ❑ Other (specify equipment t and model in Section E on Pae 2). ❑ Other (specify equipment type and model in Section E on Pae 2). Tank ID: T3 Diesel #2 20k Tank ID: T4 BIO 99 20k )C In -Tank Gauging Probe. Model: 846390-109 x! In -Tank Gauging Probe. Model: 846390-109 IC Annular Space or Vault Sensor. Model: 794380420 >n Annular Space or Vault Sensor. Model: 794380420 ❑ 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: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: b Tank Overfill / High -Level Sensor. Model: 846390-109 w/ Buzzer an Tank Overfill / High -Level Sensor. Model: 846390-109 wi Buzzer I Other (specify equipment t e and model in Section E on Pae 2). j Others cif ui ment typ2 and model in Section E on Pae 2). Dispenser ID: 19M Dispenser ID: 199 %7 Dispenser Containment Sensor(s). Model: 794380-208 x Dispenser Containment Sensor(s). Model: 794380-208 'b Shear Valve(s). x Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). I Dispenser Containment Floats and Chain(s). Dispenser ID: 20M Dispenser ID: 20s K' Dispenser Containment Sensor(s). Model: 794380-208 x Dispenser Containment Sensor(s). Model: 794380-208 x Shear Valve(s). x Shear Valve(s). i i Dispenser Containment Floats and Chains . Dispenser Containment Floats and Chain(s). Dispenser ID: 21M DispenserID: 219 K- Dispenser Containment Sensor(s). Model: 794380-208 x- Dispenser Containment Sensor(s). Model: 794380-208 x Shear Valve(s). x Shear Valve(s). i i Dispenser Containment Floats and Chains Dispenser Containment Floats and Chain(s). -it the tacmty contains more tanks or dispensers, copy this Corm. include lntormauon for every tams and dispenser aline faculty. 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 verity 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): x System set-up Wr Alarm history report Technician Name (print): James Blaine Signature: Certification No.: V -R# - B43163 / ICC# - 8469775 License. 0 .. 804431 Testing Company Name: Jones Covey Group, Inc. Phone No.: 88( 8 ) 972-7581 Testing Company Address: 9595 Lucas Ranch Rd.#100 Rancho Cucamonga CA,91730 Date of Testing/Servicing: 0 5 / 11 / 2 0 1 7 Monitoring System Certification Page of 12/07