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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 LIST systems within 30 days of test date. A. General Information Pilot Flying 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 aEeroEriate boxes to indicatespecific equipment ins ected/serviced: Tank ID: 91 Tank Tank ID: ,4_ In-Tank Gauging Probe. Model: 847390-107 ❑ In-Tank Gauging Probe. Model: � Annular Space or Vault Sensor. Model: 794380-303 ❑ Annular Space or Vault Sensor. Model: C Piping Sump/Trench Sensor(s). Model: 794380-208 ❑ Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: 794380-208 ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: ML[)-HC ❑ Mechanical Line Leak Detector. Model: C Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: >c Tank Overfill/High-Level Sensor. Model Flapper valve ❑ Tank Overfill/High-Level Sensor. Model: C Other(specify equipment t e and model in Section E on Pae 2). ❑ Others ci equipment t e and model in Section E on Pae 2). TanklD: TanklD: f- In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: L Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: E Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: C Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: C Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: C Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: C Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: C Other seecifx a ui ment t e andmodel in Section E on Pae 2L ❑ Other(se2cify a ui ment ty2e and model in Section E on Pae 2. Dispenser ID: Dispenser ID: L Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: C Shear Valve(s). ❑ Shear Valve(s). C Dispenser Containment Floats and Chains. ❑ Dispenser Containment Floats and Chains. Dispenser ID: Dispenser ID: C Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: C Shear Valve(s). ❑ Shear Valve(s). C Disenser Containment Float(sj and Chains. ❑ Dispenser Containment Floats and Chains. Dispenser ID: Dispenser ID: E Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: L Shear Valve(s). a Shear Valve(s). E Dispenser Containment Floats and Chains ❑ Dis enser Containment Float(sj 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 - 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 Pian 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): ki System set-up ki Alarm history report Technician Name(print): Daniel Visser Signature: 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 12/07