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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#618 Bldg No.-1501 Site Address: 1501 N. Jack Tone Road city: Ripon Zip: 95366 Facility Contact Person: Holly Marlowe Contact Phone No.:( 9 t 599-4141 Make/Model of Monitoring System: VEEDER ROOT TLS-350 Date of Testing/Servicing: 5 / 14/ 2 0 1 4 B. Inventory of Equipment Tested/Certified Check the approlgriate boxes to indicatespecific a ui ment I sl ected/serviced: Tank ID: T-5 Premium 91 12,000 Gallons. Tank ID: T-6 Auto Diesel 12,000 Gallons. x In-Tank Gauging Probe. Model: 647390-109 In-Tank Gauging Probe. Model: 843790-109 x Annular Space or Vault Sensor. Model: 794380.303 z Annular Space or Vault Sensor. Model: 794380-303 x Piping Sump/Trench Sensor(s). Model: 794380-20e x Piping Sump/Trench Sensor(s). Model: 794380-208 Fill Sump Sensor(s). Model: NIA Fill Sump Sensor(s). Model: NIA x Mechanical Line Leak Detector. Model: vaponess LD-2000 x Mechanical Line Leak Detector. Model: FXIDV Electronic Line Leak Detector. Model: N/A Electronic Line Leak Detector. Model: NIA x Tank Overfill/High-Level Sensor. Model: OPW Flapper r Tank Overfill/High-Level Sensor. Model: DPW Flapper Others ci ui ent and model in Section E on Pae 2). Others ci ui ment and model in Section E on Page 2). Tank ID: NIA Tank ID: NIA In-Tank Gauging Probe. Model: NIA In-Tank Gauging Probe. Model: NIA Annular Space or Vault Sensor. Model: NIA Annular Space or Vault Sensor. Model: NIA Piping Sump/Trench Sensor(s). Model: NIA Piping Sump/Trench Sensor(s). Model: NIA Fill Sump Sensor(s). Model: NIA Fill Sump Sensor(s). Model: NIA Mechanical Line Leak Detector. Model: NIA Mechanical Line Leak Detector. Model: NIA Electronic Line Leak Detector. Model: NIA Electronic Line Leak Detector. Model: NIA Tank Overfill/High-Level Sensor. Model: NIA Tank Overfill/High-Level Sensor. Model: NIA Others a equieMent and model in Section E on Pae 2). Others i!y 2quippent and model in Section E on Pae 2). Dispenser ID: 13 Dispenser ID: 14-15 " Dispenser Containment Sensor(s). Model: — -2cle Dispenser Containment Sensor(s). Model: 7943M20e " Shear Valve(s). Shear Valve(s). Disp2nser Containment Floats and Chain(s). Disp2nser Containment Floats and Chains. Dispenser ID: 16 Dispenser ID: 19 Main Dispenser Containment Sensor(s). Model: 794380-208 " Dispenser Containment Sensor(s). Model: 794380-208 " Shear Vahre(s). " Shear Valve(s). Dis nser Containment Floats and Chains. Dispenser Containment Floats and Chain(s). Dispenser ID: 19 sat Dispenser ID: 20 Main " Dispenser Containment Sensor(s). Model: 7943e0 toe = Dispenser Containment Sensor(s). Model: 794390-208 " Shear Valve(s). " Shear Valve(s). Disp2nser Containment Floats and Chains Disp2nser Containment Floats and Chains. 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): x System set-up x Alarm history report Technician Name(print): Edwin Coreas Signature: Certification No.: 834020 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 / 14/ 2 0 1 4 Monitoring System Certification Page of 12107