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Appendix VI MONITORING SYSTEM CERTIFICATIO For Use By All Jurisdictions Within the State of Cafrforrria Authority Cited.Chapter 6.7,Health and Safety Code;Chapter 16,Division 3, Title 23, llfot'nh Coda 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 Flying J#618 Facility Name: y 9 Bldg.No.: Site Address: 1501 N.Jack Tone Rd. City: Ripon, CA. Zip: 95366 Facility Contact Person: Manager Contact phone No.:( 09 ) 5994141 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 c equipment Insl ected/serviced: Tank ID: Vent Box Tank ID: Bio Shed sump ❑ In-Tarn Gauging Probe. Model: N/A ❑ In-Tank Gauging Probe. Model: N/A ❑ Annular Space or Vault Sensor. Model: N/A ❑ Annular Space or Vault Sensor. Model: N/A tti Piping Sump/Trench Sensor(s). Model: 794380-208 w/794380-304 u_i Piping Sump/Trench Sensor(s). Model: 794380.208 wi 7943 soa ❑ Fill Sump Sensor(s). Model: N/A ❑ 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: N/A ❑ Electronic Line Leak Detector. Model: N/A ❑ Tank Overfill/High-Level Sensor. Model: WA ❑ Tank Overfill/High-Level Sensor. Model: N/A ❑ Others equipment a and model in Section E on Pa 2. ❑ Other(sp220 2quipment bo and model in Section E 2aEage 2L_ Tank ID: Tank ID: ❑ In-Tarn 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 2guipMent and model in Section E on PM 2). ❑ Other(spe2yy 2gulpMent type and model in Section E on Pa 2). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ D ar Containment Floats and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Di nser Containment Floats and Chain(s). ❑ Di2pner Containment Floats and Chain(s). DispenserID: I Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ nser Containment Floats and Chains ❑ Di2pner Containment Float(s)and Chain(s). 'if the facility contains more tanks or dispensers,copy this form. Include Information for every tarn and dispenser at the facility. C. Certification - i certify that the equipment identified in this document was Inspectedtserviced 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 aWy). C System -up C Alarm history report Technician Nara(print): James Blaine Suture: Certification No.:V-R#-B43163 / ICC#-8469775 LicenE° ,,jo.: 804431 Testing Company Name: Jones Covey Group, Inc. Phone No.: 8( 88 ) 972-7581 Testing Company Address: 9595 Lucas Ranch Rd.#100 Rancho Cucamonga CA,91730 Date of TestingtServicing:0 5 /03/ 2 0 1 7 Monitoring System Certification Pap of 12107