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Appendix VI MAY 2 4 2018 MONITORING SYSTEM CERTIFICATION ENVIRONMENTAL For Use By All Jurisdictions Within the State of California HEALTH DEPARTMENT 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 Travel Plaza #617 Bldg No.: 15237 N. Thornton Road Site Address: 15237 N. Thornton Road Facility Contact Person: Manager Make/Model of Monitoring System: TLS -350 Diesel AST City: Lodi Contact Phone No.: ( 209 Zip: 95242 339-4066 Date of Testing/Servicing: 4 /25/ 1 8 Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicate specific equipment inspected/serviced: Tank ID: T-1 Diesel #2 20,000 Gal Tank ID: T-2 Diesel #2 20.000 Gal X In -Tank Gauging Probe. Model: &46390-109 X- In -Tank Gauging Probe. Model: 846390-109 x Annular Space or Vault Sensor. Model: 794390420 )C Annular Space or Vault Sensor. Model: 794380-420 Piping Sump/ Trench Sensor(s). Model: C Piping Sump /Trench Sensor(s). Model: Fill Sump Sensor(s). Model: 7 Fill Sump Sensor(s). Model: x -j Mechanical Line Leak Detector. Model: VMI LD3000 _ x Mechanical Line Leak Detector. Model: VMI LD3000 I Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: x] Tank Overfill / High -Level Sensor. Model: 846390-109 w/Buzzer x Tank Overfill / High -Level Sensor. Model: 846390-109 wiBuzzer - Other(specify e ui ment tyee and model in Section E on Page 2). Other (seecify equipment t e and model in Section E on Pae 2). Tank ID: T-3 Diesel #220, 000 Gal Tank ID: T-4 8109920,000Gal x In -Tank Gauging Probe. Model: 846390-109 x In -Tank Gauging Probe. Model: 846390-109 x7 Annular Space or Vault Sensor. Model: 794380-420 x Annular Space or Vault Sensor. Model: 794380-420 Piping Sump /Trench Sensor(s). Model: L Piping Sump / Trench Sensor(s). Model: 7 Fill Sump Sensor(s). Model: C Fill Sump Sensor(s). Model: 7 Mechanical Line Leak Detector. Model: E Mechanical Line Leak Detector. Model: i Electronic Line Leak Detector. Model: - Electronic Line Leak Detector. Model: x7 Tank Overfill / High -Level Sensor. Model: 846390-109 wiBuzzer x Tank Overfill / High -Level Sensor. Model: 846390-109 wiBuzzer Other(specify equipment t e and model in Section E on Pa e 2). Other(specify equipment t e and model in Section E on Page 2). Dispenser ID: 19 M Dispenser ID: 19 S x Dispenser Containment Sensor(s). Model: 794380-208 x Dispenser Containment Sensor(s). Model: 794380-208 x Shear Valve(s). _ _ x Shear Valve(s). Dispenser Containment Floats and Chain(s). Dispenser Containment Floats and Chain(s). Dispenser ID: 20 M Dispenser ID: 20 S XI Dispenser Containment Sensor(s). Model: 794380-208 x Dispenser Containment Sensor(s). Model: 794380-208 r] Shear Valve(s). x Shear Valve(s). I Dispenser Containment Floats and Chain(s). r Dispenser Containment Floats and Chain(s). Dispenser ID: 21 M Dispenser ID: 21 s Ki Dispenser Containment Sensor(s). Model: 794380-208 x- Dispenser Containment Sensor(s). Model: 794380-208 >Sj Shear Valve(s). )r- Shear Valve(s). I Dispenser Containment Floats and Chains E 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/seryiced 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): 9 System set-up 9 Alarm history report _L Technician Name (print): Jose Ochoa Signature: 1v Certification No.: 835931 License. No.: 8004551 Testing Company Name: Jones Covey Group, Inc. Phone No.:( ) 9 12-7581 Testing Company Address: 9595 Lucas Ranch Rd.#100 Rancho Cucamonga CA,91730 Date of Testing/Servicing: 4 / 25 / 2 0 1 8 Monitoring System Certification Page of 12/07