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0 RECEIVED Appendix VI MAY 0 5 2013 SAN JOAQUIN COUNly MONITORING SYSTEM CERTIFICATION ENVIRONMENTAL 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 PIIOt FI In J 617 Facility Name: Y g Bldg.No.: site Address: 15100 N. Thornton Road City; Lodi Zip: 95242 Facility Contact Person: Holly Marlowe Contact Phone No.: 20( 9 ) 339-4066 Make/Model of Monitoring System: VR TLS-350 Date of Testing/Servicing:5 /2 / 2 0 1 3 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates ecific a ui ment insl iected/serviced: Tank ID: 87Tank#1 Tank ID: 87Tank#2 K_ In-Tank Gauging Probe. Model: 846390-109 �v In-Tank Gauging Probe. Model: 846390-109 >C Annular Space or Vault Sensor. Model: 794380-303 C Annular Space or Vault Sensor. Model: 794380-303 C Piping Sump/Trench Sensor(s). Model: 794390-208 C Piping Sump/Trench Sensor(s). Model: 794390-208 ,c Fill Sump Sensor(s). Model: 794390-208 PO Fill Sump Sensor(s). Model: 794390-208 E Mechanical Line Leak Detector. Model: ,d1 Mechanical Line Leak Detector. Model: LD3000 E Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ,C Tank Overfill/High-Level Sensor. Model: Flapper valve 41 Tank Overfill/High-Level Sensor. Model: Flapper valve ❑ Other(specify equipment t e and model in Section E on Pae 21. ❑ Others ci equipment t e and model in Section E on Pa e2. Tank ID: 87 Tank#3 Tank ID: 87 Tank#4 ,c In-Tank Gauging Probe. Model: 846390-109 x1 In-Tank Gauging Probe. Model: 846390-109 Annular Space or Vault Sensor. Model: 794380-303 C Annular Space or Vault Sensor. Model: 794380-303 Piping Sump/Trench Sensor(s). Model: 794390-208 C Piping Sump/Trench Sensor(s). Model: 794390-208 Fill Sump Sensor(s). Model: 794390-208 C Fill Sump Sensor(s). Model: 794390-208 ,C- Mechanical Line Leak Detector. Model: )c Mechanical Line Leak Detector. Model: LD3000 E Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: x❑ Tank Overfill/High-Level Sensor. Model: Flapper valve ,O Tank Overfill/High-Level Sensor. Model: Flapper valve E Other s ecif a i ment tXEe and model in Section E on Pae 2). ❑ Other scif a ui ment tXee and model in Section E on Pae 2). Dispenser ID: 1-2 Dispenser ID: 3-4 'f_ Dispenser Containment Sensor(s). Model: 794390-208 'L; Dispenser Containment Sensor(s). Model: 794390-208 ' Shear Valve(s). )4❑ Shear Valve(s). Dispenser Containment Floats and Chain(s). ❑ Dis nser Containment Floats and Chains. Dispenser ID: 5-6 Dispenser ID: 7-8 >E Dispenser Containment Sensor(s). Model: 794390.208 C Dispenser Containment Sensor(s). Model: 794390-208 )c Shear Valve(s). >d Shear Valve(s). L Dispenser Containment Floats and Chain(s). ❑ Dis22nser Containment Floats and Chains. Dispenser ID: 9-10 Dispenser ID: 11-12 >E Dispenser Containment Sensor(s). Model: 794390-208 )U Dispenser Containment Sensor(s). Model: 794390-208 >� Shear Valve(s). )�j Shear Valve(s). E Dis nser Containment Floats and Chains ❑ 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 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): 8 System set-up ®Alarm history report Technician Name(print): Daniel Visser Signature: ��a Certification No.: A31963 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 / 2 0 1 3 Monitoring System Certification Page of 12107