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Appendix VI JUN 0 9 2i' yNVIRONMENTA+ . MONITORING SYSTEM CERTIFICATION '"r--^''I,J q4 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 City: Lodi Zip: 95242 Facility Contact Person: Manager Contact Phone No.: 20( 9 1 339-4066 Make/Model of Monitoring System: TLS 350 Date of Testing/Servicing: 0 5 / 13/ 2 0 1 5 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: T1 Diesel 20K Tank ID: T2 Diesel 20K C In-Tank Gauging Probe. Model: 846390-109 » In-Tank Gauging Probe. Model: 846390-109 XO Annular Space or Vault Sensor. Model: 794380.420 93 Annular Space or Vault Sensor. Model: 7943eo-420 ❑ Piping Sump/Trench Sensor(s). Model: N/A ❑ Piping Sump/Trench Sensor(s). Model: N/A ❑ Fill Sump Sensor(s). Model: N/A ❑ Fill Sump Sensor(s). Model: N/A )❑ Mechanical Line Leak Detector. Model: VMI LD3000 x7 Mechanical Line Leak Detector. Model: VMl LD3000 ❑ Electronic Line Leak Detector. Model: N/A ❑ Electronic Line Leak Detector. Model: N/A xg Tank Overfill/High-Level Sensor. Model: 846390-109 w/Buzzer )q Tank Overfill/High-Level Sensor. Model: 846390-109 W/Buzzer ❑ Other(specify a ui ment type and model in Section E on Pae 2). ❑ Other(specify equipment t e and model in Section E on Pae 2). Tank ID: T3 Diesel 20K Tank ID: T4 Bio Diesel 20K a❑ In-Tank Gauging Probe. Model: 846390-109 C In-Tank Gauging Probe. Model: 846390-109 >a Annular Space or Vault Sensor. Model: 794840-420 C Annular Space or Vault Sensor. Model: 794340-420 ❑ Piping Sump/Trench Sensor(s). Model: N/A ❑ Piping Sump/Trench Sensor(s). Model: N/A ❑ Fill Sump Sensor(s). Model: N/A ❑ Fill Sump Sensor(s). Model: N/A ❑ Mechanical Line Leak Detector. Model: N/A ❑ Mechanical Line Leak Detector. Model: N/A ❑ Electronic Line Leak Detector. Model: N/A ❑ Electronic Line Leak Detector. Model: N/A 1] Tank Overfill/High-Level Sensor. Model: 846390-109 W/Buzzer ,[] Tank Overfill/High-Level Sensor. Model: 846390-109 w/Buzzer ❑ Other(specify equipment t e and model in Section E on Page 2). ❑ Other s ecif equipment t e and model in Section E on Page 2). Dispenser ID: 19M Dispenser ID: 19S • Dispenser Containment Sensor(s). Model: 794380-208 n Dispenser Containment Sensor(s). Model: 794380-208 • Shear Valve(s). '] Shear Valve(s). ❑ Dispenser Containment Floats and Chains . ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: 20M Dispenser ID: 20S • Dispenser Containment Sensor(s). Model: 794380-208 Ti Dispenser Containment Sensor(s). Model: 794380-208 • Shear Valve(s). C Shear Valve(s). ❑ Dispenser Containment Floats and Chains. ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: 21M Dispenser ID: 218 J❑ Dispenser Containment Sensor(s). Model: 794380-208 10 Dispenser Containment Sensor(s). Model: 794380-208 �❑ Shear Valve(s). )f7 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 in Alarm history report Technician Name(print): Issac Garcia 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 / 13/ 2 0 1 5 Monitoring System Certification Page of 12/07