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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 9 Bldg. No.: Site Address: 1501 N. Jack Tone Rd. city. Ripon Zip: 95366 Facility Contact Person: Holly Marlowe Contact Phone No.: ( 209 599-4141 Make/Model of Monitoring System: VR TLS -350 Date of Testing/Servicing: 5 /22 / 2 0 13 B. Inventory of Equipment Tested/Certified Chert tha nnnrnnriata hnvae fn indirnta cnarifir anninmant incnartad/aarvirad- Tank ID: Tank ID: L In -Tank Gauging Probe. Model: a In -Tank Gauging Probe. Model: E Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: C Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: C Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: C Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: C Electronic Line Leak Detector. Model ❑ Electronic Line Leak Detector. Model: C Tank Overfill / High -Level Sensor. Model ❑ Tank Overfill / High -Level Sensor. Model: Other(specify equipment t e and model in Section E on Page 2). ❑ Other(specify equipment t e and model in Section E on Pae 2). Tank ID: Tank ID: C In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: L Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: C Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: C Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: C Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: C Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: E Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: L Other (specify equipment t e and model in Section E on Page 2). u Others ci equipment t and model in Section E on Pae 2). Dispenser ID: 20S Dispenser ID: 21 .,�: Dispenser Containment Sensor(s). Model: 794330-208 n Dispenser Containment Sensor(s). Model: 794380-208 )E: Shear Valve(s). 1E1 Shear Valve(s). L Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: 21S Dispenser ID: 22 )E Dispenser Containment Sensor(s). Model: 794380-208 )f] Dispenser Containment Sensor(s). Model: 794380-208 r Shear Valve(s). xl Shear Valve(s). L Dispenser Containment Floats and Chain(s). u Dispenser Containment Floats and Chain(s). Dispenser ID: 22S Dispenser ID: 23 Ki Dispenser Containment Sensor(s). Model: 794380-208 n Dispenser Containment Sensor(s). Model: 794380-208 ;ri Shear Valve(s). n Shear Valve(s). 7 Dispenser Containment Floats and Chains 11 ❑ Dispenser Containment Floats and Chain(s). `If the facility contains more tanks or dispensers, copy this Corm. Include intormation for every tank and dispenser at the !acuity. 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.: 88( 8 ) 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