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0 0 UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION 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 installation,testing and servicing of monitoring equipment.A separate certification or report must be prepared for each monitoring system control vanel 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 Facility Name: PILOT-FLYING#617 Bldg.No.:15100 Site Address: 15100 THORNTON RD. City: LODI Zip: Facility Contact Person: Jose Contact Phone No.: 2( 09 )339-4066 Make/Model of Monitoring System: TLS-350 Date of Testing/Servicing: 10 / 27 / 11 B. Invent0 of E ul ment Tested/Certified:Check the appropriate boxes to indicate specific equipment installed/inspected/serviced: Tank ID. T-2 87 UNLEADED 20,000 GALLON Tank ID: T-4 87 UNLEADED 20,000 GALLON ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: M Mechanical Line Leak Detector. Model: LD-3000 M Mechanical Line Leak Detector. Model: STP-MLD-HC ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment a and model in Section E on Pae 2). ❑ Other(specify ui ment ty2e and model in Section E on Page 2). Tank ID: T-5 PREMIUM 12,000 GALLON Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: M Mechanical Line Leak Detector. Model: LD-2000 ❑ 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: ❑ Other(specify equipment a and model in Section E on Page 2). ❑ Other(specify ui ment type and model in Section E on Page 2). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). - ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment E Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ((q�ttrr 11 C3 Dispenser Containment Float(s)and Chain(s). ❑ Dis enser Containment Float(s)and 1falri w Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s) k,, su,, =iJVet�, �) ia�svL. ❑ Shear Valve(s). L) Shear Valve(s). _„ ❑Di ser Containment Floats and Chains . ❑ Di er Containment Floats at d' hA a7 " *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 installed/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): ®System set-up ill Alarm history report Technician Name(print):Frank Vasquez Signature: ---��- 1--3 Certification No.: B39396 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: 10 / 27 / It Page 1 of