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RECEIVED Appendix VI JUN 0 2 214 MONITORING SYSTEM CERTIFICATIO�---NVIR,I NMENTAL HEALTH 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, C9JWt W 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: y 9 Bldg.No.: Site Address: 15100 N Thornton Rd City: Lodi Zip: 95242 Facility Contact Person: Manager Contact Phone No.: 20( 9 ) 339-4066 Make/Model of Monitoring System: TLS-350 Date of Testing/Servicing:0 5 / 15/ 2 0 1 4 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment ins cted/serviced: Tank ID: Tank ID: In-Tank Gauging Probe. Model: L 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�specifX 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: F- In-Tank Gauging Probe. Model: n In-Tank Gauging Probe. Model: L Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: C Piping Sump/Trench Sensor(s). Model: D Piping Sump/Trench Sensor(s). Model: C Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: - Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: C Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model:- Tank Overfill/High-Level Sensor. Model: _ I I Tank Overfill/High-Level Sensor. Model: Others ecif e ui ment t e and model in Section E on Pae 2). Others ecif e ui ment type and model in Section E on Pae 2. Dispenser ID: 22M Dispenser ID: 22S K Dispenser Containment Sensor(s). Model: 794380-208 'U Dispenser Containment Sensor(s). Model: 794380-209 X Shear Valve(s). �] Shear Valve(s). Dispenser Containment Floats and Chain(s). rl Dispenser Containment Floats and Chain(s). Dispenser ID: 23M Dispenser ID: 23S X Dispenser Containment Sensor(s). Model: 794380-209 C Dispenser Containment Sensor(s). Model: 794390-208 x Shear Valve(s). Mf Shear Valve(s). Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain(s. Dispenser ID: 24M Dispenser ID: 24S C Dispenser Containment Sensor(s). Model: 794380-208 ❑ Dispenser Containment Sensor(s). Model: 7943e0-208 x Shear Valve(s). SFJ Shear Valve(s). - Dispenser Containment Floats and Chains ❑ Dis nser 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 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): ❑System set-up ❑Alarm history resort Issac Garcia Technician Name(print): Signature: Certification No.: 842806 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 5 / 15/ 2 0 1 4 Monitoring System Certification Page of 12/07