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r Appendix V1MONITORING SYSTEM CERTIFICATION 0- IUIr',`f 0 2 2017 For Use By All Jurisdictions Within the State of California Authority Cited:Chapter 6,7, Health and Safety Code;Chapter 16, Division 3, 'Title wwe H,EALT Regulations I� i'. E t , 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 ownerloperator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Pilot Flying J 618 Bld No.: Facility Name: Y g Site Address: 1501 N Jacktone Rd City: Ripon Zip: 95366 Facility Contact Person: Manager Contact Phone No.:( 9 i 599-4141 Make/Model of Monitoring System: TLS 350 Date of TestingiServicing:0 5 IO 1 J 2 0 1 7 B. Inventory of Equipment Tested/Certified Check the aepropriate boxes to indicate specific ufi Ment 1nspected/serviced: -- TanklD: TanklD: a In-Tank Gauging Probe. Model: In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: _ Annular Space or Vault Sensor. Madel: Piping Sump/Trench Sensor(s). Model: - Piping Sump I Trench Sensor(s). Model: FII 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 I High-Level Sensor. Model: Tank Overfill/High-Level Sensor. Model: Other(specify a ui ment and model in Section E on Page 2). Others ci a ui ment a and model in Section E on Pa e 2). Tank ID: TankID: In-Tank Gauging Probe. Model: In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: Piping Sump I 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(specMequipment=and model in Section E on Pae 2). Other s cif ui ment a and model in Section E on Pa Dispenser ID: 23s Dispenser ID: 24M Dispenser Containment Sensor(s). Model 794380-208 Dispenser Containment Sensor(s). Model: 794380-208 Shear Valve(s). - Shear Valve(s). Dispenser Containment Floats and Chain(s). _ Dispenser Containment Float`s and Chains. Dispenser ID: z4s Dispenser ID: 25M Dispenser Containment Sensor(s). Model: 794380-208 - Dispenser Containment Sensor(s). Model: 794380-2as Shear Valve(s). Shear Valve(s). - Dispenser Containment Float(s)and Chain(s). - Dispenser Containment Floats'and Chain(s). Dispenser ID: 255 Dispenser ID: 26M Dispenser Containment Sensor(s). Model: 794380-208 Dispenser Containment Sensor(s). Model: 794380-208 ShearValve(s). Shear Valve(s). Disp2nser.Containment Floats and Chain(s - 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 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): )a System set-up XAlarm tory eport Technician Name(print): Daniel Marroquin Signature: Certification No.: 842621 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:0 5 IO 112 0 1 7 Monitoring System Certification page of 12107