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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION <br /> Authority Cited:Chapter 6.7,Health and Safety Code;Chapter 16, Division 3, Title 23, California Code of Regulations <br /> This form must be used to document installation,testing and servicing of monitoring equipment.A separate certification or report must <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: 15100 N.Thornton Rd. City: Lodi,CA Zip.95242 <br /> Facility Contact Person: Manager Contact Phone No.:(___j <br /> Make/Model of Monitoring System: Veeder-Root TLS-350 Date of Testing/Servicing: 5 / 5 / 20 <br /> B. Invento of E of meet Tested/Certified:Check the appropriate boxes to indicate specific equipment installed/inspected/serviced: <br /> Tank ID: Tank ID: <br /> ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: <br /> ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: <br /> ❑ Piping Sump/Trench Sensor(s). Model: E Piping Sump/Trench Sensor(s). Model: <br /> ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: <br /> ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: VMI LD30M <br /> ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: <br /> ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: <br /> ❑ Other(specify equipment a and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). <br /> Tank ID: Tank ID: <br /> ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: <br /> ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: <br /> • Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: <br /> ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: <br /> ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: <br /> ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: <br /> ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: <br /> ❑ 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). <br /> Dispenser ID: 21 Main&Sat'21 Dispenser ID: 22 Main <br /> M Dispenser Containment Sensor(s). Model: 794380-322 M Dispenser Containment Sensor(s). Model: 794380-322 <br /> M Shear Valve(s). M Shear Valve(s). <br /> ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). <br /> Dispenser ID: 22 Sat Dispenser ID: 23 Main&Sat'23 <br /> ® Dispenser Containment Sensor(s). Model: 794380-352 El Dispenser Containment Sensor(s). Model: 794380-322 <br /> ® Shear Valve(s). M Shear Valve(s). <br /> ❑ Di ser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain(s). <br /> Dispenser ID: 24 Main&Sat'24 Dispenser ID: 25 Main&Sat'25 <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 /> ❑Di enser Containment Floats and Chains. ❑ Dis ser Containment Flo! s 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 ®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 />