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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION 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 installation, 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 #618 Bldg. No.: Site Address: 1501 Jack Tone Rd. City: Rlpon,CA Zip: 95366 Facility Contact Person: Manager Contact Phone No.:( 0920 599-4141 Make/Model of Monitoring System: Veeder-Root TLS -350 Date of Testing/Servicing: 5 / 24 / 20 R- InvP.ntnry of Raninment Tested/Certified: Check the annrnnriate boxes to indicate snecific eauinment installed/ insnected/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 a and model in Section E on Pa e 2). ❑ Other (specify 2guipment type 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 equipment a and model in Section E on Pae 2). ❑ Other (specify equipment and model in Section E on Page 2). Dispenser ID: 24 SAT Dispenser ID: 25 M ® Dispenser Containment Sensor(s). Model: 794380-208 M Dispenser Containment Sensor(s). Model: 794380-208 ® Shear Valve(s). M Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 25 SAT Dispenser ID: 26 M la1 Dispenser Containment Sensor(s). Model: 794380-208 M Dispenser Containment Sensor(s). Model: 794380-208 ® Shear Valve(s). M Shear Valve(s). ❑ Dispenser Containment Flo!!W and Chain(s). ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: 26 SAT Dispenser ID: 27 M ® Dispenser Containment Sensor(s). Model: 794380-208 M Dispenser Containment Sensor(s). Model: 794380-208 • Shear Valve(s). ® Shear Valve(s). ElDispenser Containment Floa s and Chain(s). ❑ Di user Containment Float(s) and Chin 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 installed/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 ® Alarm history report Technician Name (print): Frank Vasquez Signature: ---P— 1 Certification No.: B39396 License No.: 804431 Testing Company Name: Jones Covey Group, Inc. Phone No.:(_ 909 ) 972-7581 Testing Company Address: 9595 Lucas Ranch Rd., #100, Rancho Cucamonga, CA 91730 Date of Testing/Servicing: 5 / 24 / 2011 Page 1 of