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f-IVEC) Appendix VI 0 9 2015 ENVIRONMENTAL, MONITORING SYSTEM CERTIFICATION fJr-AI-o..,^ -r79 n-rq Ar..^IT 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-FI In J#617 Facility Name: y 9 Bldg.No.: Site Address: 15100 N.Thornton 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 / 13/ 2 0 1 5 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates ecific equipment inspected/serviced: 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: ❑ 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(specify equipment t e and model in Section E on Pa2e 2). ❑ Other(s2ecify equipment t e 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: ❑ 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(specify eq ui ment type and model in Section E on Pae 2). ❑ Other(specify equipment t e and model in Section E on Pae 2). Dispenser ID: 22M Dispenser ID: 229 C Dispenser Containment Sensor(s). Model: 794380-209 x Dispenser Containment Sensor(s). Model: 794380-208 )0 Shear Valve(s). n Shear Valve(s). ❑ Dispenser Containment Floats and Chains . Ll Dispenser Containment Float(s)and Chain(s). Dispenser ID: 23M Dispenser ID: 23S C Dispenser Containment Sensor(s). Model: 794380-208 U Dispenser Containment Sensor(s). Model: 794380-208 JO Shear Valve(s). U Shear Valve(s). ❑ Dispenser Containment Floats and Chains. ❑ Dis enser Containment Floats and Chains. DispenserlD: 24M Dispenser ID: 249 ki Dispenser Containment Sensor(s). Model: 794380-208 n Dispenser Containment Sensor(s). Model: 794380-208 jo Shear Valve(s). n 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): 91 System set-up C Alarm history report Technician Name(print): Issac Garcia Signature: �s _Z_ — - Certification No.: 842806 License.No.: 804431 Testing Company Name: Jones Covey Group, Inc. Phone No.: 88( 8 1 972-7581 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