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01 RECEIVED Appendix VI MAY 2 5 2018 MONITORING SYSTEM CERTIFICATIO ':N®'11ZO\:111':\�I:,®L FIEALT For Use By All Jurisdictions Within the State of California 1)V'PA R `I L N T 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 618 Facility Name: Bldg.No.: Site Address: 1501 N.Jack Tone City: Ripon Zip: 95366 Facility Contact Person: Manager Contact Phone No.:(209 599-4141 Make/Model of Monitoring System: TLS-350 Date of Testing/Servicing: 5 /3 / 2 0 1 8 B. Inventory of Equipment Tested/Certified Check thea ro nate boxes to Indicates ecific ul ment ins cted/serviced: Tank ID: T8 Bio-Diesel 20,000 Tank ID: TLM Sump x❑ In-Tank Gauging Probe. Model: 846391-109 r In-Tank Gauging Probe. Model: )U Annular Space or Vault Sensor. Model: 794380-303 C Annular Space or Vault Sensor. Model: z❑ Piping Sump/Trench Sensor(s). Model: 794380-208 /794380-304 rc Piping Sump/Trench Sensor(s). Model: 794380-208 /794380-304 >:❑ Fill Sump Sensor(s). Model: 794380-208 /794380-304 L Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: E Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: C Electronic Line Leak Detector. Model: x❑ Tank Overfill/High-Level Sensor. Model: OPw Flapper C Tank Overfill/High-Level Sensor. Model: ❑ Others eci equipment t e and model in Section E on Pae 2). C Others eci a ui ment type and model in Section E on Pae 2). Tank ID: N.Transition Sump Tank ID: S.Transition Sump n in-Tank Gauging Probe. Model: r In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: C Annular Space or Vault Sensor. Model: ,C7 Piping Sump/Trench Sensor(s). Model: 794380-208 /794380-304 )c Piping Sump/Trench Sensor(s). Model: 794380-208 /794380-304 ❑ Fill Sump Sensor(s). Model: E Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: C Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: r- Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: = Tank Overfill/High-Level Sensor. Model: ❑ Others ci equipment t e and model in Section LaZagLEL. C Other(specify equipment t e and model in Section E on Pae 2. Dispenser ID: Dispenser lD: ❑ Dispenser Containment Sensor(s). Model: C Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). C Shear Valve(s). ❑ Dispenser Containment Float�sj and Chain(s). E Dispenser Containment Floats and Chains. Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: F Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). C Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). H C Dispenser Containment Floats and Chains. Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: E Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). L Shear Valve(s). ❑ Dispenser Containment Floats and Chains C Dis enser Containment Floats 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 - 1 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,l have also attached a copy of the report;(check all that apply): 9 System set-up 9 Alarm history report -�� Technician Name(print): Rogelio Valencia Signature: Certification No.: 844220 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 /3 / 2 0 1 8 Monitoring System Certification Page of 12/07