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0 FIT-CEIVED Appendix VI i .9 71 1Jnr? to ,N l 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 Pilot Travel Centers LLC#618 Facility Name: Bldg.No.: Site Address: 1501 N.Jack Tone Rd. City. Ri[pon Zip: 95366 Facility Contact Person: Manager Contact Phone No.:(209 209-599-4141 Make/Model of Monitoring System: TLS-350 Date of Testing/Servicing: 5 /23/ 2 0 1 8 B. Inventory of Equipment Tested/Certified Check the aeerogriate boxes to indicates ific 2sulement Ins acted/serviced: Tank ID: T-4 8712,000 Gal Tank ID: C! In-Tank 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: lid', Mechanical Line Leak Detector. Model: Fx1y 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 equipment type and model in Section E on Pae 2). 7 Other(specify equipment t e and model in Section E on Pae 2. Tank ID: Tank ID: - In-Tank 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: Others ci a ui ment type and model in Section E on Pae 2). Others ci a ui ment txee and model in Section Eon Dispenser ID: Dispenser ID: Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). Shear Valve(s). ❑ Dis22nser Containment Floats and Chains. Disp2nser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: n Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). Shear Valve(s). ❑ Dis enser Containment Float(s)and Chains. Dispenser Containment Floats and Chain(s). Dispenser ID: Dispenser ID: 2. Dispenser Containment Sensor(s). Model LDispenser Containment Sensor(s). Model: -1 Shear Valve(s). Shear Valve(s). E Dis enser Containment Floats and Chains L 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 verify that this information Is correct and a Piot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,1 have also attached a copy of the report;(check all that apply): System set-up Alarm history report ^� Technician Name(print): Jose Ochoa Signature: Certification No.: 835931 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 /2 3/ 1 8 Monitoring System Certification Page of 12107