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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#818 Bldg.No.: 1501 Site Address: 1501 N.Jack Tone Road City: p:Ripon CA, Zi 95366 Facility Contact Person: Holly Marlowe Contact Phone No.:( 9 599-4141 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 aperogriate boxes to indicates eclfic equipment Inspected/serviced: Tank ID: N/A Tank ID: N/A In-Tank Gauging Probe. Model: N/A in-Tank Gauging Probe. Model: N/A Annular Space or Vault Sensor. Madel: N/A Annular Space or Vault Sensor. Model: N/A Piping Sump/Trench Sensor(s). Model: N/A Piping Sump/Trench Sensor(s). Model: NIA Fill Sump Sensor(s). Model: N/A Fill Sump Sensor(s). Model: NIA Mechanical Line Leak Detector. Model: N/A Mechanical Line Leak Detector. Model: N/A Electronic Line Leak Detector. Model: NIA Electronic Line Leak Detector. Model: N/A Tank Overfill/High-Level Sensor. Model: NIA Tank Overfill/High-Level Sensor. Model: N/A Other(speci a ui ent type and model in Section E on Page 2). Other(s i e ui ment and model in Section E on Page 2). Tank ID: N/A Tank ID: N/A In-Tank Gauging Probe. Model: N/A In-Tank Gauging Probe. Model: NIA Annular Space or Vault Sensor. Model: N/A Annular Space or Vault Sensor. Model: N/A Piping Sump/Trench Sensor(s). Model: NIA Piping Sump/Trench Sensor(s). Model: NIA Fill Sump Sensor(s). Model: N/A Fill Sump Sensor(s). Model: N/A 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 ci ui ent t e and model in Section E on Pae 2). Other s29 ui ment and model in Section E on Pae 2). Dispenser ID: 26 sat Dispenser ID: 27 Main Dispenser Containment Sensor(s). Model: 794380-208 Dispenser Containment Sensor(s). Model: 794380.208 Shear Valve(s). Shear Valve(s). Dis enser Containment Floats and Chain(s). Disg2nser Containment Floats and Chains. Dispenser ID: 27 sat Dispenser ID: Sin x Dispenser Containment Sensor(s). Model: 794380-208 x Dispenser Containment Sensor(s). Model: 794380-208 x Shear Valve(s). x Shear Valve(s). Dis enser Containment Floats and Chain(s). Dispenser Containment Floats and Chains. Dispenser ID: 28 sat Dispenser ID: 29 Main Dispenser Containment Sensor(s). Model: 794380.208 Dispenser Containment Sensor(s). Model: 794380-208 Shear Valve(s). ` Shear Valve(s). Disp2nser Containment Floats and Chains — Disp2nser Containment Float�sl 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 verity 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 Edwin Coreas ~' Technician Name(print): Signature: Certification No.: B34020 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 12/07