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Appendix VI RECENED .JUN 0 12017 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of Californiavv I(��(� — LTH Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Tlt�'IIvv Z3, iC,�llfornia Code of Regulations DL, , . _ -, — 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: Flying J #617 Bldg. No.: Site Address: 151000 N. Thornton Rd. Facility Contact Person: Manager Make/Model of Monitoring System: TLS 350 Diesel AST B. Inventory of Equipment Tested/Certified City: Lodi, CA. Contact Phone No.: ( 209 Zip: 95242 339-4066 Date of Testing/Servicing: 0 5/ 02 / 2 0 1 7 -It the tacilrty contains more tanks or dispensers, copy this Corm. Include intormation for every tanK ano aispenser at the taaaty. 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): x System set-up r Alarm history report Technician Name (print): James Blaine Signature: Certification No.: V -R# - B43163 / ICC# . 8469775 Licens • Ivo.: 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 VnecK ine aepropnaie oozes io molcate S eCITIC 2quipment insi iectea/servicea: Tank ID: Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ 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: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment t e and model in Section E on Pae 2). ❑ Other (specify 2guipment type and model in Section E on Pae 2). Tank ID: Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ 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: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Others ci aqui ment type and model in Section E on Pae 2 . -- Other (specify equipment type and model in Section E on Page 2). Dispenser ID: 22M Dispenser ID: 22S x. Dispenser Containment Sensor(s). Model: 794380-208 X Dispenser Containment Sensor(s). Model: 794890-20e X Shear Valve(s). "' Shear Valve(s). CI Dispenser Containment Floats and Chain(s). Dispenser Containment Floats and Chain(s). Dispenser ID: 23M Dispenser ID: 23s X Dispenser Containment Sensor(s). Model: 794360-208 z Dispenser Containment Sensor(s). Model: 794380-208 z Shear Valve(s). Shear Valve(s). ii Dispenser Containment Floats and Chain(s). Dispenser Containment Floats and Chain(s). Dispenser ID: 24M Dispenser ID: 24s Dispenser Containment Sensor(s). Model: 294380-208 z Dispenser Containment Sensor(s). Model: 794380-20e Shear Valve(s). x Shear Valve(s). n Dispenser Containment Floats and Chains Dispenser Containment Floats and Chain(s). -It the tacilrty contains more tanks or dispensers, copy this Corm. Include intormation for every tanK ano aispenser at the taaaty. 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): x System set-up r Alarm history report Technician Name (print): James Blaine Signature: Certification No.: V -R# - B43163 / ICC# . 8469775 Licens • Ivo.: 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