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RECEIVED Appendix VI AU-1 C 2 2313 ENVIRONMENTAL MONITORING SYSTEM CERTIFICATION HEALTH DEH?ARTMENT 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 PILOT FLYING J #617 Facility Name: -- --------__--- 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 7/02/ 2 0 1 3 B. Inventory of Equipment Tested/Certified Check the aeeroeriate boxes to Indicatespecific equipment ins ed/serviced: Tank ID: OIL WATER SEPERATOR TANK 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: _ 3 Piping Sump/Trench Senors). Model: Fill Sump Sensor(s). Model: 3 Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: 7 Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: = Electronic Line Leak Detector. Model: x Tank Overfill/High-Level Sensor. Model: HIGH LEVEL sENSORONLY D Tank Overfill/High-Level Sensor. Model: _ Other(specify equipment and model in Section E on Pa 2). 1 3 Other(specify equipment type and model in Section E on Pae 2)- Tank .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: D Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: 7 Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: _ 7 Tank Overfill/High-Level Sensor. Model: Other(specify t(Luigment type and model in Section E on Page 2). D Other(specify equiEMent and model in Section E on Pa 2). Dispenser ID: #22 DIESEL MASTER _ _ Dtapenser ID: #22 DIESEL SATELLITE r Dispenser Containment Sensor(s). Model: VR-208 " Dispenser Containment Sensor(s). Model: VR-208 Shear 'r Shear Valve(s). ,< Shear Valve(s). Dispenser Containment Floats and Chain(s). -1 Dispenser Containment Floats and Chains. Dispenser ID: 423 DIESEL MASTER Dlspenser ID: #23 DIESEL SATELLITE K Dispenser Containment Sensor(s). Model: VR-208 x; Dispenser Containment Senors). Model: VR-208 >< Shear Valve(s). in Shear Valve(s). Dispenser Containment Floats and Chain(s). _ Dispenser Containment Floats and Chain(s). Dispenser ID: #24 DIESEL MASTER Dispenser ID: #24 DIESEL SATELLITE ,r Dispenser Containment Sensor(s). Model: VR-208_ _ z Disperser Containment Sensor(s). Model: VR-toe x. Shear Valve(s). >< Shear Valve(s). Dispenser Containment Floats and Chains _ Dise2nser Containment Floats and Chain(s)- the hains.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 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): x System set-up x Alarm his r Technician Name(print): JOHNNY SOUZA Signature: Certification No.: A30918 _ License.No.: $044 Testing Company Name: Jones Covey Group,Inc. Phone No.: $( 88 ) 972-7581 Testing Company Address: 9595 Lucas Ranch Rd.#100 Rancho Cucamonga CA,91730 Date of Testing/Servicing:0 7/0 2/ 2 0 1 3 , Monitoring System Certification Page of 12/07