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10 - <br /> JUN 2 2 2011 <br /> UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIZATION <br /> "V <br /> Authority Cited.-Chapter 6 7,Health and Safe , ,I <br /> Safety Code;Chapter 16,Division 3, Title 23, California C , KATION <br /> This form must be used to document installation,testing and servicing of monitoring equipment.A separate c"&�6'1 ilieior <br /> be prepared for each monitoring system control panel by the technician who performs the work. A copy of this form must be provided <br /> to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST syste ms <br /> within 30 days of test date. <br /> A.General Information <br /> Facility Name: Pilot-Flying J#617 Bldg.No.: <br /> Site Address: 15 100 N.Thornton Rd. City: Lodi,CA Zip:95242 <br /> Facility Contact Person: Manager Contact Phone No.: <br /> Make/Model of Monitoring System: Veeder-Root TLS-350 Date of Testing/Servicing: 5 / 5 2011 <br /> B. Invento!j of Equ!jginent Tested/Certified:Check the appropriate boxes to indicate specific equipment installed/inspected/serviced: <br /> Tank ID: TKI-Diesel 20,000 Tank ID: TK2-Diesel 20,000 <br /> • In-Tank Gauging Probe. Model: 846390-109 M In-Tank Gauging Probe. Model: 846390-109 <br /> • Annular Space or Vault Sensor. Model: 794380-302 M Annular Space or Vault Sensor. Model:-794380-302 <br /> • Piping Sump/Trench Sensor(s). Model: 794380-322 M Piping Sump/Trench Sensor(s). Model: 794380-352 <br /> • Fill Sump Sensor(s). Model: N/A Q Fill Sump Sensor(s). Model: N/A <br /> M Mechanical Line Leak Detector. Model: Fe-Petro STP-MLD M Mechanical Line Leak Detector. Model: VMI LD3000 <br /> Ll Electronic Line Leak Detector. Model: N/A C3 Electronic Line Leak Detector. Model: N/A <br /> * Tank Overfill/High-Level Sensor. Model: 846390-109 M Tank Overfill/High-Level Sensor. Model: 846390-109 <br /> * Other(specify equipment type and model in Section E on Page 2). 0 Other(specify e4uipment type and model in Section E on Pa e 2). <br /> Tank ID: TK3-Diesel 20,000 Tank ID: TK4-87 Unleaded 20,000 <br /> • In-Tank Gauging Probe. Model: 846390-109 M In-Tank Gauging Probe. Model: 846390-109 <br /> • Annular Space or Vault Sensor. Model: 794380-302 M Annular Space or Vault Sensor. Model:-794380-302 <br /> • Piping Sump/Trench Sensor(s). Model: 794380-352 M Piping Sump/Trench Sensor(s). Model: 794380-352 <br /> • Fill Sump Sensor(s). Model: N/A U Fill Sump Sensor(s). Model: N/A <br /> M Mechanical Line Leak Detector. Model: Fe-Petro,STP-MLD M Mechanical Line Leak Detector. Model: <br /> U Electronic Line Leak Detector. Model: N/A U Electronic Line Leak Detector. Model: <br /> * Tank Overfill/High-Level Sensor. Model: 846390-109 M Tank Overfill/High-Level Sensor. Model: 846390-109 <br /> * Other(specify equipment e and model in Section E on Page 2). U Other(specify equipment type and model in Section E on Pa e 2). <br /> Dispenser ID: 1/2 Dispenser ID: 3/4 <br /> * Dispenser Containment Sensor(s). Model: 794380-322 M Dispenser Containment Sensor(s). Model: 794380-322 <br /> * Shear Valve(s). M Shear Valve(s). <br /> * Dispenser Containment Float(s)and Chain(s). Q Dispenser Containment Float(s)and Chain(s). <br /> Dispenser ID: 5/6 Dispenser ID: 7/8 <br /> * Dispenser Containment Sensor(s). Model: 794380-322 M Dispenser Containment Sensor(s). Model: 794380-322 <br /> * Shear Valve(s). M Shear Valve(s). <br /> * Dispenser Containment Floats and Chain(s). Ll Dispenser Containment Float(s)and Chain(s). <br /> Dispenser ID: 9/ 10 Dispenser ID: 11/12 <br /> • Dispenser Containment Sensor(s). Model: 794380-322 M Dispenser Containment Sensor(s). Model: 794380-322 <br /> • Shear Valve(s). M Shear Valve(s). <br /> ElDiMser Containment Floats and Chains . L1 DiM=er Containment Floats and Chains . <br /> *If the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility. <br /> C. Certification - I certify that the equipment identified in this document was installed/inspected/serviced in accordance with the <br /> manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this <br /> information is correct and a Plot Plan showing the layout of monitoring equipment For any equipment capable of generating such reports,I <br /> have also attached a copy of the report(check all that apply): M System set-up M Alarm history report <br /> Technician Name(print):Robert Vargas Signature: <br /> Certification No.: B34019 License No.:03-1643 <br /> Testing Company Name: Jones Covey Group,Inc. phone No.:( 909 ) 972-7581 <br /> Testing Company Address: 9595 Lucas Ranch Rd.,#100,Rancho Cucamonga,CA 91730 Date of Testing/Servicing: 5 5 2011 <br /> Page 1 of <br />