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Appendix VI MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California 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 City: Lodi Facility Contact Person: Manager Contact Phone No.: ( 209 Zip: 95242 339-4066 Make/Model of Monitoring System: TLS -350 Diesel AST Date of Testing/Servicing: 4 /25/ 1 8 B. Inventory of Equipment Tested/Certified Chock the annronriate boxes to indicate snecific enuinment insnerted;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.- odel:Tank TankOverfill / High -Level Sensor. Model: Tank Overfill / High -Level Sensor. Model: Other (sEecify equipment t e and model in Section E on Pae 2). Other(specify equipment t e 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: C Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: E Piping Sump / Trench Sensor(s). Model: Fill Sump Sensor(s). Model: E Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: E 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 t e and model in Section E on Pae 2). Dispenser ID: 22 M Dispenser ID: 22 S x Dispenser Containment Sensor(s). Model: 794380-208 ' _ Dispenser Containment Sensor(s). Model: 794380-208 x Shear Valve(s). YL Shear Valve(s). Dispenser Containment Floats and Chains . C Dispenser Containment Float(s) and Chain(s). Dispenser ID: 23 M Dispenser ID: 23 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: 24 M Dispenser ID: 24 s x Dispenser Containment Sensor(s). Model: 794380-208 r Dispenser Containment Sensor(s). Model: 794380-208 xj Shear Valve(s). )E Shear Valve(s). ;j Dispenser Containment Floats and Chains L Dispenser Containment Floats and Chain(s). -it the facility contains more tanks or dispensers, copy this Corm. inauae mtormation for every tanK ana aispenser at the racmty. 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 9 Alarm history report_L Technician Name (print): Jose Ochoa Signature: Certification No.: 835931 License. No.: 8004551 Testing Company Name: Jones Covey Group, Inc. Phone No.:( /972-75811 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 12107