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J -- Appendix VI JUN 0 12016 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 Facility Name: Pilot-Flying J#617 Bldg.No.: Site Address: 15100 N.Thornton Rd. City: Lodi Zip: 95242 Facility Contact Person: Manager Contact Phone No.:(209 ) 339-4066 Make/Model of Monitoring System: TLS 350 Date of Testing/Servicing: 0 5 /03/ 2 0 1 6 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates ecific equipment ins ected/serviced: Tank ID: T1 8720K Tank ID: T28720K x❑ In-Tank Gauging Probe. Model: 846390-109 x❑ In-Tank Gauging Probe. Model: 846390-109 Annular Space or Vault Sensor. Model: 794380-303 XD Annular Space or Vault Sensor. Model: 794380-303 91 Piping Sump/Trench Sensor(s). Model: 794380-208 x❑ Piping Sump/Trench Sensor(s). Model: 794380-208 Fill Sump Sensor(s). Model: 794380-208 )G Fill Sump Sensor(s). Model: 794380-208 ❑ Mechanical Line Leak Detector. Model: N/A C Mechanical Line Leak Detector. Model: vMi LD3000 ❑ Electronic Line Leak Detector. Model: N/A ❑ Electronic Line Leak Detector. Model: 4 Tank Overfill/High-Level Sensor. Model: OPW Flapper x❑ Tank Overfill/High-Level Sensor. Model: OPW Flapper ❑ Other(specify equipment t e and model in Section E on Pae 2). ❑ Other(specify equipment t e and model in Section E on Pae 2)_ Tank ID: T38720K Tank ID: T48720K In-Tank Gauging Probe. Model: 846390-109 x❑ In-Tank Gauging Probe. Model: 846390-109 )] Annular Space or Vault Sensor. Model: 794380-303 ki Annular Space or Vault Sensor. Model: 794380-303 .0 Piping Sump/Trench Sensor(s). Model: 794380-208 x[7 Piping Sump/Trench Sensor(s). Model: 794380-208 j7 Fill Sump Sensor(s). Model: 794380-208 X] Fill Sump Sensor(s). Model: 794380-208 ❑ Mechanical Line Leak Detector. Model: a0 Mechanical Line Leak Detector. Model: Fe Petro STP MLD-HC ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ,,0 Tank Overfill/High-Level Sensor. Model: OPW Flapper )E Tank Overfill/High-Level Sensor. Model: Phil-rite Flapper ❑ Other(seecifX a ui ment type and model in Section E on Pae 2). ❑ Others ecif equipment t e and model in Section Dispenser ID: 1-2 Dispenser ID: 3-4 • Dispenser Containment Sensor(s). Model: 794380-208 n Dispenser Containment Sensor(s). Model: 794380-208 HCl Shear Valve(s). n Shear Valve(s). ❑ Dispenser Containment Floats and Chains. ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: 5-6 Dispenser ID: 7-8 U Dispenser Containment Sensor(s). Model: 794380-208 U Dispenser Containment Sensor(s). Model: 794380-208 )0 Shear Valve(s). JE] Shear Valve(s). ❑ Dis enser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: 9-10 Dispenser ID: 11-12 )❑ Dispenser Containment Sensor(s). Model: 794380-208 n Dispenser Containment Sensor(s). Model: 794380-208 C Shear Valve(s). C Shear Valve(s). ❑ Dispenser Containment Floats and Chains 1 ❑ Dispenser Containment Floats 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 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 19 Alarm history report i Garca -- — -- Technician Name(print): Issac Signature: - - Certification No.: 842806 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: 0 5 / 3 / 2 0 1 6 Monitoring System Certification Page of 12/07