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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 Facility Name: Pilot Flying J 617 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: 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: i Other(s2ecify 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). Tank ID: Tank ID: r_i In-Tank Gauging Probe. Model: i 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: i 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: 7 Other(specify a ui ment a and model in Section E on Page 2). Other(specify a ui ment type and model in Section Dispenser to: 22M Dispenser ID: 22S x-i Dispenser Containment Sensor(s). Model: 794390.208 Dispenser Containment Sensor(s). Model: 794 W209 K, Shear Valve(s). Shear Valve(s). Dispenser Containment Floats and Chain(s). Dispenser Containment Floats and Chain(s). Dispenser ID: 23M Dispenser ID: 23S Dispenser Containment Sensor(s). Model: 794390-208 Dispenser Containment Sensor(s). Model: 794390-208 Ki Shear Valve(s). Shear Valve(s). 1 Dispenser Containment Floats and Chain(s). Dispenser Containment Floats and Chain(s). Dispenser ID: 24M Dispenser ID: 24S Dispenser Containment Sensor(s). Model: 794390-208 Dispenser Containment Sensor(s). Model: 794390-208 Shear Valve(s). Shear Valve(s). Dispenser Containment Floats and Chains Dispenser Containment Float(s)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): z System set-up x'Alarm history report Technician Name(print): Daniel Visser Signature: 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