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Appendix VI 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 618 Facility Name: Bldg.No.: Site Address: 1501 N.Jack Tone City: Ripon Zip: 95366 Facility Contact Person: Manager Contact Phone No.:(20_ 9 599-4141 Make/Model of Monitoring System: TLS-350 Date of Testing/Servicing: 5 /3 / 2 0 1 8 B. Inventory of Equipment Tested/Certified Check the approErlate boxes to indicates ecific a ui ment Ins cted/serviced: Tank ID: vent box Tank ID: Bio Shed Sump ❑ In-Tank Gauging Probe. Model: C In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: c Annular Space or Vault Sensor. Model: )C Piping Sump/Trench Sensor(s). Model: 794380-208 /794380-304 )t Piping Sump/Trench Sensor(s). Model: 794380-208 /794380-304 ❑ Fill Sump Sensor(s). Model- C Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: C Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: C Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: C Tank Overfill/High-Level Sensor. Model: ❑ Other s eci equipment t e and model in Section E on Pae 2). C Other s eci a ui ment ty2e and model in Section E on Pae 2). Tank ID: Tank ID: F1 In-Tank Gauging Probe. Model: r- In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: C Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: C Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: C Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: C 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 Page 21. C Otherts ]:)ecify equipment t e and model in Section Eon Pa e 2. DispenserlD: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: C Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). C Shear Valve(s). ❑ Dispenser Containment Floats and Chains. C DisE2nser Containment Float�sj and Chain(s). Dispenser ID: DlspenserlD: ❑ Dispenser Containment Sensor(s). Model- r Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). C Shear Valve(s). ❑ Dispenser Containment Float�sj and Chains. C Dispenser Containment Floats and Chains. Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: L Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). C 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 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 apply): to System set-up ><Alarm history report _ Technician Name(print): Rogelio Valencia Signature: Certification No.: 644220 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