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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 Pilot FI in J 618 Facility Name: y g Bldg. No.: Site Address: 1501 N. Jack Tone Rd. city Ripon Zi, 95366 Facility Contact Person: Holly Marlowe Make/Model of Monitoring System: VR TLS -350 B. Inventory of Equipment Tested/Certified Contact Phone No.: 20( 9 ) 599-4141 Date of Testing/Servicing: 5 /22 2 0 13 u ulc --y —1U .UID II WIG tnllna UI UIJt.JC11JGl J, uut./y ullb lura 11. IIIuIUUC II IIVr i l lauurl IUI uvury tarn artU U15PUMer at tre taGlilty. 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): ❑ System set-up ❑ Alarm history report Technician Name (print): Edwin Coreas. Signature: Certification No.: 834020 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: 5 / 22 / 2 0 13 Monitoring System Certification Page of 12/07 VnecK ine appropriaie Doxes io moicate S eCITIC a UI mens ins ecteo/serviceo: Tank ID: 91 Tank ID: Auto Diesel xi - In -Tank Gauging Probe. Model: 847390-109 '41 In -Tank Gauging Probe. Model: 847390-109 Annular Space or Vault Sensor. Model: 794380-303 'U Annular Space or Vault Sensor. Model: 794380-303 rL Piping Sump / Trench Sensor(s). Model: 794380-208 )�_l Piping Sump / Trench Sensor(s). Model: 794380-208 E Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: tc Mechanical Line Leak Detector. Model: LD2000 x❑ Mechanical Line Leak Detector. Model: Fx1DV E Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: x= Tank Overfill / High -Level Sensor. Model: Flapper x❑ Tank Overfill / High -Level Sensor. Model: Flapper C Other(specify equipment t e and model in Section E on Pae 2). ❑ Other(specify equipment t e and model in Section E on Tank ID: ows Tank ID: Pi[: In -Tank Gauging Probe. Model: 847390-104 ❑ In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 794380-303 ❑ Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: 794380-208 ❑ Piping Sump / Trench Sensor(s). Model: C Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: E Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: Flapper ❑ Tank Overfill / High -Level Sensor. Model Other(specify equipment a and model in Section E on Pae 2). ❑ Other(specify equipment t e and model in Section Eon Dispenser ID: 13 Dispenser ID: 14-15 tE Dispenser Containment Sensor(s). Model: 794380-208 If[I Dispenser Containment Sensor(s). Model: 794380-208 Shear Valve(s). 'f7 Shear Valve(s). C Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: 16 Dispenser ID: 19 Dispenser Containment Sensor(s). Model: 794380-208 x❑ Dispenser Containment Sensor(s). Model: 794380-208 X Shear Valve(s). 1�1 Shear Valve(s). Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: 193 Dispenser ID: 20 'cl Dispenser Containment Sensor(s). Model: 794380-2081 Dispenser Containment Sensor(s). Model: 794380-208 x❑ Shear Valve(s). )F1 Shear Valve(s). Dispenser Containment Floats and Chains ❑ Dispenser Containment Floats and Chain(s). u ulc --y —1U .UID II WIG tnllna UI UIJt.JC11JGl J, uut./y ullb lura 11. IIIuIUUC II IIVr i l lauurl IUI uvury tarn artU U15PUMer at tre taGlilty. 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): ❑ System set-up ❑ Alarm history report Technician Name (print): Edwin Coreas. Signature: Certification No.: 834020 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: 5 / 22 / 2 0 13 Monitoring System Certification Page of 12/07