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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 PllOt Flying J 618 Facility Name: Y g Bldg. No.: Site Address: 1501 N. Jackton Rd. city Ripon Zip. 95366 91 Facility Contact Person: Holly Marlowe Make/Model of Monitoring System: VR TLS -350 Inventory of Equipment Tested/Certified Contact Phone No.:20( 9 ) 599-4141 Date of Testing/Servicing: 5 /22 2 0 13 L M lawny wr uan rs I l lus rains Ur uisNansars, cupy rnis rut in. rncruue rnrorrnauon tor every tanK ana aispenser at the raou¢y. 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: r'`"t' 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 12107 t,nutm mea ro nate poxes to marcate s ecmc a ut mem insl lectea/servicea: Tank ID: Tank ID: In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: F- Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: E Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: L Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: E Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: E Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: L 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). ❑ Other (specify equipment t e and model in Section E on Pae 2). Tank ID: Tank ID: F-. In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: E Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: E Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: E Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: E 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: L Other (spedify equipment t e and model in Section E on Pae 2 . u Other(specify equipment t and model in Section E on Pae 2 . Dispenser ID: 29S Dispenser ID: 30 xL Dispenser Containment Sensor(s). Model: 794380-208 )�] Dispenser Containment Sensor(s). Model: 794380-208 Shear Valve(s). 1�1 Shear Valve(s). C Dispenser Containment Floats and Chain(s).-11Dispenser Containment Floats and Chain(s). Dispenser ID: 30SDispenser ID: )E: Dispenser Containment Sensor(s). Model: 794390-208 ❑ Dispenser Containment Sensor(s). Model: K- Shear Valve(s). ❑ Shear Valve(s). l_ Dis enser Containment Floats and Chain(s). A ❑ Dispenser Containment Floats and Chains . Dispenser ID: Dispenser ID: :1 Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: :1 Shear Valve(s). ❑ Shear Valve(s). Dispenser Containment Floats and Chains ❑ Dispenser Containment Floats and Chain(s). L M lawny wr uan rs I l lus rains Ur uisNansars, cupy rnis rut in. rncruue rnrorrnauon tor every tanK ana aispenser at the raou¢y. 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: r'`"t' 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 12107