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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 Zip: 95242 Facility Contact Person: Manager Contact Phone No.: ( 209 ) 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 Check the annronriate boxes to indicate snecific enuinment inspected/serviced: Tank ID: Tank ID: In -Tank Gauging Probe. Model: C In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: _ E 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: L Electronic Line Leak Detector. Model: Tank Overfill 1 High -Level Sensor. Model: E Tank Overfill / High -Level Sensor. Model: Other (seecify equipment t e and model in Section E on Page 2). Other (seecify a ui ment type and model in Section E on Page 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: Other(specify equipment t e and model in Section E on Pace 2). Other(specify equipment t e and model in Section E on Page 2). Dispenser ID: 25 M Dispenser ID: 25 S K� Dispenser Containment Sensor(s). Model: 794380-208 x Dispenser Containment Sensor(s). Model: 794380-209 KI Shear Valve(s). Shear Valve(s). Dispenser Containment Floats and Chains . Dispenser Containment Float(s) and Chain(s). Dispenser ID: 26 M Dispenser ID: 26 S KI Dispenser Containment Sensor(s). Model: 794380-208 x Dispenser Containment Sensor(s). Model: 794380-208 X1 Shear Valve(s). x Shear Valve(s). Dispenser Containment Floats and Chain(s). Dispenser Containment Floats and Chains . Dispenser ID: 27 M Dispenser ID: 27 S x Dispenser Containment Sensor(s). Model: 794380-208 x Dispenser Containment Sensor(s). Model: 794380-208 Shear Valve(s). 'f Shear Valve(s). ❑ Dispenser Containment Floats and Chains L Dispenser Containment Floats and Chain(s). -it the tacwty contains more tanKs or aispensers, copy mis term. mcivae mtormauon Tor every tarns ana aispenser at the Tacnity. 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): r. System set-up x Alarm history report Technician Name (print): Jose Ochoa Signature: Certification No.: 835931 License. No.: 8004551 Testing Company Name: Jones Covey Group, Inc. Phone No.:C 972-7581 Testing Company Address: 9595 Lucas Ranch Rd.#100 Rancho Cucamonga CA,91730 Date of Testing/Servicing: 4 125 / 2 0 1 8 Monitoring System Certification Page of 12/07