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Appendix VI MONITORING SYSTEM CERTIFICATION:" -f For Use By All Jurisdictions Within the State of Calfomia Authority Cited:Chapter 6.7,Health and Safety Code;Chapter 16,Division 3, Title 23,`C#11fDm1&Code hof 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 Flying J#618 Facility Name: y g Bldg.No.: Site Address: 1501 N.Jack Tone Rd. City. Ripon, CA. Zip: 95366 Facility Contact Person: Manager Contact Phone No.:( 09 ) 599-4141 Make/Model of Monitoring System: TLS 350 Date of Testing/Servicing:0 5 /0 3/ 2 0 1 7 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate Ific 2quipment insl iected/serviced: Tank ID: Ts B10 Diesel 20k Tank ID: Tau Sump )C In-Tarn Gauging Probe. Model: 846391-log ❑ In-Tank Gauging Probe. Model: N/A Annular Space or Vault Sensor. Model: 794380.303 ❑ Annular Space or Vault Sensor. Model: N/A m Piping Sump/Trench Sensor(s). Model: 794380.208 wi 794380-304 xp Piping Sump/Trench Sensor(s). Model: 794380-208 wi 794380-304 ,c Fill Sump Sensor(s). Model: 794380-208 wi 794380-304 ❑ FII Sump Sensor(s). Model: NSA ❑ Mechanical Line Leak Detector. Model: N/A ❑ Mechanical Line Leak Detector. Model: N/A ❑ Electronic Line Leak Detector. Model: N/A ❑ Electronic Line Leak Detector. Model: N/A rd❑ Tank Overfill/High-Level Sensor. Model: OPW Flapper ❑ Tank Overfill/High-Level Sensor. Model: N/A ❑ Other equipment and model in Section E on Page 2). ❑ Others equipment MLe and model in Section E on PaQe 2). Tank ID' North Transition Sump Tank ID: South Transition Sump ❑ In-Tank Gauging Probe. Model: N/A ❑ in-Tank Gauging Probe. Model: N/A ❑ Annular Space or Vault Sensor. Model: NIA ❑ Annular Space or Vault Sensor. Model: N/A Piping Sump/Trench Sensor(s). Model: 794380-208 w1794380-304 m Piping Sump/Trench Sensor(s). Model: 794380-208 wi 794380-304 ❑ Fill Sump Sensor(s). Model: NIA ❑ Fill Sump Sensor(s). Model: N/A ❑ 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: NSA ❑ Tank Overfill/High-Level Sensor. Model: N/A ❑ Other u!ppent a and model in Section E on Pa 2). ❑ 2guipMerrt and model in Section E on Pa 2). Dispenser 10: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Digp2aw Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: Dispenser ID: ❑ Disperser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chains. ❑ Dispenser Containment Floats and Chains. Dispenser ID: DispenserID: ❑ Dispenser Containment Sensor(s). Model: 1 ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ nser 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 facility. C. Certification - I certify that the equipment identified In this document was Inspectedifserviced 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,l have also attached a copy of the report;(check ap that y). 19 System set-up ®Alarm history report Technician Name(print): James Blaine Signature:_ - Certification No.: V-R##-B43163 i Ick#-8469775 License. 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 TestingrSeroicing:0 5 /03/ 2 0 1 7 Monhoring System Certification Pop of 12107