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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 Pilot Flying J 617 Facility Name: y 9 Bldg.No.: site Address: 15100 N. Thornton Road city: Lodi Zip; 95242 Facility Contact Person: Holly Marlowe Contact Phone No.: 20( 9 ) 339-4066 Make/Model of Monitoring System: VR TLS-350 Date of Testing/Servicing: 5 /2 / 2 0 1 2 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: Diesel Tank#1 Tank ID: Diesel Tank#2 In-Tank Gauging Probe. Model: 846390-109 x In-Tank Gauging Probe. Model: 846390-109 Annular Space or Vault Sensor. Model: 794390-420 x Annular Space or Vault Sensor. Model: 794390-020 Piping Sump/Trench Sensor(s). Model: Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: LD3000 Fill Sump Sensor(s). Model: n Mechanical Line Leak Detector. Model: x- Mechanical Line Leak Detector. Model LD3000 Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: 846390-109 x_ Tank Overfill/High-Level Sensor. Model: 846390-109 Other(specify equipment t e and model in Section E on Page 2). X- Other(specify equipment t e and model in Section E on Page 2). Tank ID: Diesel Tank#3 Tank ID: x In-Tank Gauging Probe. Model: 846390-109 _ In-Tank Gauging Probe. Model: x Annular Space or Vault Sensor. Model: 794390420 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: 646390-109 Tank Overfill/High-Level Sensor. Model: x Others ecif a ui ment ty2e and model in Section E on Pae 2). Other(specify a ui ment type and model in Section E on Pa e 2). Dispenser ID: 19M Dispenser ID: 19s x Dispenser Containment Sensor(s). Model: 794390-208 xJ Dispenser Containment Sensor(s). Model: 794390-208 x Shear Valve(s). ' Shear Valve(s). Dispenser Containment Floats and Chains. Dispenser Containment Floats and Chain(s). Dispenser ID: 20M Dispenser ID: 20S x Dispenser Containment Sensor(s). Model: 794390-208 x Dispenser Containment Sensor(s). Model: 794390-208 x Shear Valve(s). x Shear Valve(s). Dispenser Containment Floats and Chain(s). Dis enser Containment Floats and Chain(s). Dispenser ID: 21M Dispenser ID: 21S x Dispenser Containment Sensor(s). Model: 794390-208 x- Dispenser Containment Sensor(s). Model: 794390-208 x Shear Valve(s). Ici Shear Valve(s). Dispenser Containment Floats and Chains 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 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 capable of generating such reports,I have also attached a copy of the report;(check all that apply): ><System set-up is Alarm history report �y Technician Name(print): Daniel Visser Signature: /�r Certification No.: A31963 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:5 /2 / 2 0 1 2 Monitoring System Certification Page of 12107