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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 . A. General Information Facility Name : Pilot Flying J 1017 Bldg . No. : 345 Roth Rd Lathrop CA 95330 Site Address : 345 Roth Rd , City: French Camp Zip : 95231 Facility Contact Person : Manager Contact Phone No . : ( 865 588-7488 Make/Model of Monitoring System : TLS-350 Date of Testing/Servicing : 0 8 / 23 / 2 0 1 8 B . Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment ins ected/serviced : Tank ID: Tank-1 Unleaded 16,000 Gallons Tank ID : Tank-2 Premium 9,000 Gallons M7 In-Tank Gauging Probe. Model : 846390-110 ) C In-Tank Gauging Probe. Model : 846390-110 wC Annular Space or Vault Sensor. Model : 794380-303 >r Annular Space or Vault Sensor. Model : 794380-303 )1 Piping Sump / Trench Sensor(s) . Model : 794380-208 / 794380-304 >r Piping Sump / Trench Sensor(s) . Model : 794380-208 / 794380-304 tc FIII Sump Sensor(s) . Model : 794380-208 / 794380-304 %C FIII Sump Sensor(s) . Model : 794380-208 / 794380-304 C Mechanical Line Leak Detector, Model : VMI LD2000 )E Mechanical Line Leak Detector. Model : VMl LD2000 ❑ Electronic Line Leak Detector, Model : C Electronic Line Leak Detector, Model : W Tank Overfill / High-Level Sensor. Model : OPw71SO Flapper valve xC Tank Overfill / High- Level Sensor. Model : oPw71So Flapper valve ❑ Other (specify equipment t e and model in Section E on Pae 2) . C Other (specify equipment t e and model in Section E on Page 2) , Tank ID : Tank [ D * n In-Tank Gauging Probe. Model : C in-Tank Gauging Probe. Model : ❑ Annular Space or Vault Sensor, Model : E Annular Space or Vault Sensor. Model : ❑ Piping Sump / Trench Sensor(s) . Model : C Piping Sump / Trench Sensor(s) . Model : ❑ Fill Sump Sensor(s) . Model : E Fill Sump Sensor(s) . Model : ❑ Mechanical Line Leak Detector, Model : E Mechanical Line Leak Detector. Model : ❑ Electronic Line Leak Detector. Model : L 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 Page 2) . E Other (specify aquiment t e and model in Section E on Pae 2) , Dispenser ID : 1 -2 Dispenser ID : 34 �j Dispenser Containment Sensor(s) , Model : 794380-208 / 794380-304 Dispenser Containment Sensor(s) . Model : 794380-208 / 794380-304 )(I Shear Valve(s) . )C Shear Valve(s) . ❑ Dispenser Containment Floats and Chain (s). E Dispenser Containment Floats and Chain (s). Dispenser ID: 5-6 Dispenser ID : 7-8 *1 Dispenser Containment Sensor(s) . Model : 794380-208 / 794380-304 *- Dispenser Containment Sensor(s) . Model : 794380-208 / 794380-304 U Shear Valve(s) . C Shear Valve(s) . ❑ Dispenser Containment Floats and Chains . C Dispenser Containment Floats and Chains . Dispenser ID : 9-10 Dispenser ID : 11 -12 >d Dispenser Containment Sensor(s) , Model : 794380-208 / 794380-304 s�: Dispenser Containment Sensor(s) . Model : 794380-208 / 794380-304 )0 Shear Valve(s) . Shear Valve(s) . ❑ Dispenser Containment Floats and Chains C Dispenser Containment Floats and Chain (s), * 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): 91 System set-up K Alarm history report Technician Name (print) : Jose Ochoa Signature : Certification No. : 835931 License. No. : 8004551 Testing Company Name : Jones Covey Group Inc. Phone No. : 88( 8 ) 972-7581 Testing Company Address : 9595 Lucas Ranch Rd . # 100 Rancho Cucamonga Ca , 91730 Date of Testing/Servicing : 0 8 / 2 3 / 2 0 1 8 Monitoring System Certification Page of 12/07