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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.:(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 aeeroeriate boxes to indicatespecific equipment ins acted/serviced: Tank ID: Tank ID: ❑ 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: L Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: C Tank Overfill/High-Level Sensor. Model: ❑ Others eci equipment t e and model in Section E on Pae 2). C Others eci equipment t e and model in Section E on Pae 2). Tank ID: Tank ID: ❑ In-Tank Gauging Probe. Model: F- In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: r Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: C Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: E Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: E Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: r- Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: C Tank Overfill/High-Level Sensor. Model: ❑ Others cifit equipment t e and model in SectionE on Pa e 2). L Other(specify equipment t e and model in Section E on Pae 2). Dispenser ID: 26 Sat Dispenser ID: 27 main C Dispenser Containment Sensor(s). Model: 794380-208 Jr Dispenser Containment Sensor(s). Model: 794380-208 C Shear Valve(s). r Shear Valve(s). ❑ Disp2nser Containment Floats and Chain(s). C Disp2nser Containment Floats and Chains. Dispenser ID: 27 Sat i 28 Main Dispenser ID: 28 sat/29 Main T1 Dispenser Containment Sensor(s). Model: 794380-208 1 794380-208 *. Dispenser Containment Sensor(s). Model: 794380-208 i 794380-208 C Shear Valve(s). r Shear Valve(s). ❑ Dis22nser ContainmentFloats and Chain(s), C Dispenser Containment Floats and Chains. Dispenser ID: 29 sat i 30 Main Dispenser ID: 30 Sat C Dispenser Containment Sensor(s). Model: 794380-208 i 794380-208 r Dispenser Containment Sensor(s). Model: 794380-208 1 794380-208 C Shear Valve(s). *: Shear Valve(s). ❑ Dis nser Containment Floats and Chains I E DisE2nser 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): 91 System set-up K Alarm history report %A Technician Name(print): Rogelio Valencia Signature: L/ Certification No.: 844220 License.No.: 804431 Testing Company Name: Jones Covey Group, Inc. Phone No.:(888 972-7581 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