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RECEIVED Appendix VI MAY 2 5 20 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California ENVIRONMENTAL I I L A LT Authority Cited:Chapter 6.7, Health and Safety Code;Chapter 16, Division 3, Title 23, V 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 the approEriate boxes to Indicates ecific a ul ment Ins ected/serviced: Tank ID: Tank#1 Diesel 20,000 gal Tank ID: Tank#2 Diesel 20,000 gal x0 In-Tank Gauging Probe. Model: 847390-109 C In-Tank Gauging Probe. Model: 847390-109 Annular Space or Vault Sensor. Model: 794380-303 K_ Annular Space or Vault Sensor. Model: 794380-303 Piping Sump/Trench Sensor(s). Model: 794380-208 xC Piping Sump/Trench Sensor(s). Model: 794380-208 ❑ Fill Sump Sensor(s). Model: C Fill Sump Sensor(s). Model: I)c Mechanical Line Leak Detector. Model: Fx1VD )E Mechanical Line Leak Detector. Model: VMI LD2000 ❑ Electronic Line Leak Detector. Model: C Electronic Line Leak Detector. Model: x❑ Tank Overfill/High-Level Sensor. Model: DPW Flapper xC Tank Overfill/High-Level Sensor. Model: DPW Flapper ❑ Others eci equipment t e and model in Section E on Pae 2). C Other(specify equipment t e and model in Section E on Page 2). Tank ID: Tank#3 Diesel 20,000 gal Tank ID: Tank#4 87 12,000 gal X-� In-Tank Gauging Probe. Model: 847390-109 )V In-Tank Gauging Probe. Model: 847390-107 u❑ Annular Space or Vault Sensor. Model: 794380-303 C Annular Space or Vault Sensor. Model: 794380-303 )E Piping Sump/Trench Sensor(s). Model: 794380-208 >r Piping Sump/Trench Sensor(s). Model: 794380-208 ❑ Fill Sump Sensor(s). Model: C Fill Sump Sensor(s). Model: )�7 Mechanical Line Leak Detector. Model: VMI LD2000 ic Mechanical Line Leak Detector. Model: Red Jacket Fx7V F1 Electronic Line Leak Detector. Model: F Electronic Line Leak Detector. Model: %❑ Tank Overfill/High-Level Sensor. Model: Flapper xC Tank Overfill/High-Level Sensor. Model: DPW Flapper ❑ Other(specify a ui ment type and model in Section E on Pae 2). C Other(specify equipment t e and model in Section E on Page 2). Dispenser ID: 1/2 Dispenser ID: 3/4 �f Dispenser Containment Sensor(s). Model: 794380-208 't Dispenser Containment Sensor(s). Model: 794380-208 'C Shear Valve(s). 'C Shear Valve(s). ❑ Dispenser Containment Floats and Chains. E Dispenser Containment Floats and Chains. Dispenser ID: Dispenser ID: 7/8 x1 Dispenser Containment Sensor(s). Model: 794380-208 x Dispenser Containment Sensor(s). Model: 794380-208 C Shear Valve(s). Shear Valve(s). ❑ Dis enser Containment Floats and Chain(s). C Dispenser Containment Floats and Chain(s). Dispenser ID: 9110 Dispenser ID: 11/12 X] Dispenser Containment Sensor(s). Model: 794380-208 Dispenser Containment Sensor(s). Model: 794380-208 „❑ Shear Valve(s). tC Shear Valve(s). ❑ Dispenser Containment Floats and Chains C Dis enser 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): 9 System set-up k 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 12107