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Appendix VI JUN 0 2015 ENVIRONMENTA J 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 Facility Name: Pilot -Flying J #617 Bldg. No.: Site Address: 15100 N. Thornton Facility Contact Person: Manager City: Lodi Zip: 95242 Contact Phone No.: ( 209 ) 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 annronriate hnxes to indicate snecifir enninmpnt insnectarf/carvicerl- 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 s eci equipment t e and model in Section E on Pae 2). ❑ Other(specify 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: ❑ Others ecif a ui ment type and model in Section E on Pae 2 . ❑ Other(specify equipment t e and model in Section E on Page 2). Dispenser ID: 28M Dispenser ID: 28S • Dispenser Containment Sensor(s). Model: 794380-208 C 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: 29M Dispenser ID: 29s U Dispenser Containment Sensor(s). Model: 794380-208 SEI Dispenser Containment Sensor(s). Model: 794380-208 JO Shear Valve(s). U Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: 30M Dispenser ID: 30s )E1 Dispenser Containment Sensor(s). Model: 794380.208 C Dispenser Containment Sensor(s). Model: 794380-208 C 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 tacility. 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): la System set-up 0 Alarm history report Technician Name (print): Issae 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