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A. 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 UST systems within 30 days of test date. General Information Pilot FI In J 1017 Facility Name: y g Site Address: 345 Roth Rd. City: French Camp Bldg. Np.: 345 Roth Rtl Lathrop CA 95330 Zip: 95231 Facility Contact Person: Manager Contact Phone No.: (86� 588-7488 131 Make/Model of Monitoring System: TLS -350 B. Inventory of Equipment Tested/Certified 0 8 Date of Testing/Servicing: / / 2 0 1 8 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 Piot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, 1 have also attached a copy of the report; (check all that apply): x System set-up K Alarm history report Technician Name (print): Jose Ochoa Certification No.: 635931 Signature: License. No.: 8004551 Testing Company Name: Jones Covey Group Inc. Phone No.:( 888 Testing Company Address: 9595 Lucas Ranch Rd. #100 Rancho Cucamonga Ca, 91730 Date of Testing/Servicing: O S8 Monitoring System Certification Page of 12/07 Check theappropriate boxes to indicates ecific a ui ment ins ected/serviced: Tank ID: Tank -1 Unleaded 16,000 Gallons Tank ID: Tank -2 Premium 9,000 Gallons 91 In -Tank Gauging Probe. Model: 846390-110 K� In -Tank Gauging Probe. Model: 846390-110 Ycl Annular Space or Vault Sensor. Model: 794380-303 )r. Annular Space or Vault Sensor. Model: 794380-303 We Piping Sump/ Trench Sensor(s). Model: 794380-208 / 794380-304 tC Piping Sump /Trench Sensor(s). Model: 794380-208 / 794380-304 x❑ Fill Sump Sensor(s). Model: 794380-208/794380-304 )c Fill Sump Sensor(s). Model: 794380-208/794380-304 )(7 Mechanical Line Leak Detector. Model: VMl LD2000 )E Mechanical Line Leak Detector. Model: VMl LD2000 ❑ Electronic Line Leak Detector. Model: E Electronic Line Leak Detector. Model: X17 Tank Overfill / High -Level Sensor. Model: OPw71SO Flapper valve WC Tank Overfill / High -Level Sensor, Model: OPw71SO Flapper valve ❑ Other(specify equipment t e and model in Section E on Page 2). E Other(specify equipment t e and model in Section E on Pae 2). Tank ID: Tank ID: ❑ In -Tank Gauging Probe. Model: r In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: E Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: E Piping Sump /Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: C Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector, Model: L Mechanical Line Leak Detector. Model: n Electronic Line Leak Detector. Model: F- Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: C Tank Overfill / High -Level Sensor. Model: ❑ Other(specify equipment t e and model in Section E on Pae 2). E Other(specify equipment t e and model in Section E on Page 2). Dispenser ID: 1'2 Dispenser ID: 3A 'j Dispenser Containment Sensor(s). Model: 794390-208/794380-304 Dispenser Containment Sensor(s). Model: 794380-208/794380-304 iu Shear Valve(s). Shear Valve(s). ❑ Dispenser Containment Floats and Chains . E D enser Containment Floats and Chain(s). Dispenser ID: 5-8 Dispenser ID: 7-8 x1 Dispenser Containment Sensor(s). Model: 794380-208/794380-304 *- Dispenser Containment Sensor(s). Model: 794380-208/794380-304 C Shear Valve(s). C Shear Valve(s), ❑ Dispenser Containment Floats and Chain(s). E Dispenser Containment Floats and Chain(s), Dispenser ID: 11-12 Dispenser ID: 9-10 K-; ki Dispenser Containment Sensor(s). Shear Valve(s). Model: 794380-208/794380.304 +C Dispenser Containment Sensor(s). Shear Valve(s). Model: 794380-208/794380-304 ❑ Dis enser Containment Floats and Chains E Dispenser Containment Floats and Chain(s), 'If the facility contains more tanks or dispensers. coov this form. Include information for every tank and dispenser at the facilitv, 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 Piot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, 1 have also attached a copy of the report; (check all that apply): x System set-up K Alarm history report Technician Name (print): Jose Ochoa Certification No.: 635931 Signature: License. No.: 8004551 Testing Company Name: Jones Covey Group Inc. Phone No.:( 888 Testing Company Address: 9595 Lucas Ranch Rd. #100 Rancho Cucamonga Ca, 91730 Date of Testing/Servicing: O S8 Monitoring System Certification Page of 12/07