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RECEIVE® Appendix VI AUG C>' 2 2N3 MONITORING SYSTEM CERTIFICATION EN.1"'PrONMENTAL For Use By All Jurisdictions Within the State of California `°E-PAR(MENT Authority Cited:Chapter 6.7,Health and Safety Code;Chapter 16,Division 3, Title 23,Califomia 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 ROADCity: LODI Zip: 95242 Facility Contact Person: JOSE JIMENEZ (STORE DIRECTOR) Contact Phone No.: 20( 9 1 339-4066 Make/Model of Monitoring System: VEEDER ROOT TLS 350; Date of Testing/Servicing:0 7102/ 2 0 1 3 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: Tank ID: In-Tank Gauging Probe. Model: In-Tank Gauging Probe. Model: ,'L Annular Space or Vault Sensor. Model: 3 Annular Space or Vault Sensor. Model: C, Piping Sump/Trench Sensor(s). Model: 3 Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: 3 Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: _ 3 Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: — — 3 Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: 3 Tank Overfill/High-Level Sensor. Model: Other(specL equipment a and model in Section E on Pacie 2). 3 Others ci equipment pe 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: _j Annular Space or Vault Sensor. Model: Piping Sump!Trench Sensor(s). Model: 7 Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: 3 Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: 3 Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: 3 Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: 7 Tank Overfill/High-Level Sensor. Model: Other(specify equipment t e and model in Section E on Page 2)_ 1 - Other(specify equipment and model in Section E on Page 2). Dispenser ID:028 DIESEL MASTER _ _ Dispenser ID: -28 DIESEL SATELLITE X- Dispenser Containment Sensor(s). Model:VR-208 KJ Dispenser Containment Sensor(s)- Model: VR-2o_e_____ Ir- Shear Valve(s). 'G Shear Valve(s). Dispenser Containment Floats and Chain(s). -i Dispenser Containment Floats and Chain(s). Dispenser ID: 429 DIESEL MASTER INSpenser ID: #Y9 DIESEL SATELLfTE K Dispenser Containment Sensor(s). Model: VR-208 xi Dispenser Containment Sensor(s). Model: VR-208 K Shear Valve(s). Ki Shear Valve(s). Dispenser Containment Floats and Chains. Dispenser Containment Floats and Chain(s). Dispenser ID: #30 DIESEL MASTER Dispenser ID: #30 DIESEL SATELLME x Dispenser Containment Sensor(s). Model: VR-208 K. Dispenser Containment Sensor(s). Model: v_R_-20e x-: Shear Valve(s). x Shear Valve(s). E. Dispenser Containment Floats and Chain(s _ Dis enser 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. r 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 caab nerating such reports,I have also attached a copy of the report;(check all that apply): /S System set-up A Alar o r ort Technician Name(print): JOHNNY SOUZA Signature: —_ Certification No.: A30918 License.No.: 804431 ___ - 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 7/0 2/ 2 0 1 3 Monitoring System Certification Page of 12/07