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Ina], t Y ( J Appendix VI JUN Q 1 2017 MONITORING SYSTEM CERTIFICATION ONN'iENTAL HEALTH For Use By All Jurisdictions Within the State of California ^ , i—e , – 4 I - 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: Flying J #617 Bldg. No.: Site Address: 151000 N. Thornton Rd. Facility Contact Person: Manager Make/Model of Monitoring System: TLS 350 Diesel AST City: Lodi, CA Zip: 95242 Contact Phone No.:( 9 ) 339-4066 Date of Testing/Servicing: 0 5/ 02 / 2 0 1 7 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific eaulDment inspected/serviced: TanklD: TanklD: ❑ 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 equipment type and model in Section E on Page 2). TanklD: TanklD: ❑ 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 equipment t e and model in Section E on Pae 2). ❑ Other (specify Nuipment type and model in Section E on Pae 2). Dispenser ID: 25M Dispenser ID: 25S x-. Dispenser Containment Sensor(s). Model: 794380-208 x -i Dispenser Containment Sensor(s). Model: 794380-208 "- Shear Valve(s). r Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). 1 2 Dispenser Containment Floats and Chain(s). Dispenser ID: 26M Dispenser ID: 26s 'L Dispenser Containment Sensor(s). Model: 794380-208 X Dispenser Containment Sensor(s). Model: 794380-208 Shear Valve(s). x Shear Valve(s). u Dispenser Containment Floats and Chain(s). Dispenser Containment Floats and Chain(s). Dispenser ID: 27M Dispenser ID: 278 x- Dispenser Containment Sensor(s). Model: 794380-208 K Dispenser Containment Sensor(s). Model: 794380-208 z Shear Valve(s). x Shear Valve(s). I Dispenser Containment Floats and Chains I 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): 9 System set-up 9 Alarm history report Technician Name (print): James Blaine Signature: _ Certification No.: V -R# - B43163 / ICC# - 8469775 License. NV.. 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