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RECEIVED AUG 6 2 2013 Appendix VI ENVIRONMENTAL HEALTH DEPARTMENT 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: _PILOT FLYING J #617 Bldg.No.: Site Address: 15100 N.THORNTON ROAD City: LODI ZIP: 95242 Facility Contact Person: JOSE JIMENEZ (STORE DIRECTOR) Contact Phone No.:(209 } 339-4066 Make/Model of Monitoring System: VEEDER ROOT TLS 350,. Date of Testing/Servicing:0 7/0 21 2 0 1 3 E Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: #1 DIESEL AST _ Tank ID: 02 DIESEL AST F-, In-Tank Gauging Probe. Model: In-Tank Gauging Probe. Model: jGr Annular Space or Vault Sensor. Model: VR-420 me Annular Space or Vault Sensor. Model:VR4W >C Piping Sump/Trench Sensor(s). Model: VR-2081 TRANS SUMP 1 _ >d Piping Sump/Trench Sensor(s). Model:VR-2el1/TRANS SUMP2 D Fill Sump Sensor(s). Model:_- 3 Fill Sump Sensor(s). Model: 11 Mechanical Line Leak Detector. Model: 7 Mechanical Line Leak Detector. Model: E Electronic Line Leak Detector. Model 7 Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: 7 Tank Overfill/High-Level Sensor. Model: _ x Other(specify equipment a and model in Section E on Pae 2). 1 jfj Other(specify equipment and model in Section E on Pa e 2). Tank ID:#3 DIESEL AST Tank ID: #4 DEF UST _ In-Tank Gauging Probe. Model: _ 3 In-Tank Gauging Probe. Model: A Annular Space or Vault Sensor. Model: vR-420 Ki Annular Space or Vault Sensor. Model: VR-420 jf. Piping Sump/Trench Sensor(s). Model: VR-208/TRANS SUMP.3 XD Piping Sump/Trench Sensor(s)- Model: VR-208 r VR-208 DEF TRANS G Fill Sump Sensor(s). Model: 7 Fill Sump Sensor(s). Model: D Mechanical Line Leak Detector. Model: _ 7 Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model:__ 7 Electronic Line Leak Detector. Model: xC Tank Overfill/High-Level Sensor. Model: _ Tank Overfill/High-Level Sensor. Model: C Other(specify equipment t oe and model in Section E on Pae 2i. Other(specify equipment e and model in Section E on Pa 2). Dispenser ID: #19 DIESEL MASTER Dispenser ID: #19 DIESEL SATELLITE x Dispenser Containment Sensor(s). Model: VR-208 _ X Dispenser Containment Sensors) Model: VR-los _ >< Shear Valve(s). x Shear Valve(s). I Dispenser Containment Floats and Chain sl. Dispenser Containment Float(s)and Chain(s). Dispenser ID: #20 DIESEL MASTER Dispenser ID: M DIESEL SATELLfrE >t- Dispenser Containment Sensor(s). Model: vR-208 X Dispenser Containment Sensor(s). Model: VR-208 >f' Shear Valve(s). X Shear Valve(s). Dispenser Containment Floats and Chain(s). _ Dispenser Containment Floats and Chain(s). Dispenser ID: #21 DIESEL MASTER_ __ Dispenser ID: #21 DIESEL SATELLITE )C, Dispenser Containment Senso it Model: VR-208 X Dispenser Containment Sensor(s). Model: VR-toe fir' Shear Valve(s). Shear Valve(s). L DisR2nser Containment Floats and Chain(s 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 inspecte&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): K System set-up S Alarm hist or ort Technician Name(print): JOHNNY SOUZA Signature: certification No.:No.: A30918 License. o.. 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 7 10 2/ 2 0 1 3 Monitoring System Certification Page of 12/07