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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#615 Bldg.No.:1501 Site Address: 1501 N. Jack Tone Road City. Ripon Zip: 95366 Facility Contact Person: Holly Marlowe Contact Phone No.:( 9 ► 599-4141 Make/Model of Monitoring System: VEEDER ROOT TLS-350 Date of Testing/Servicing: 5 / 14/ 2 0 1 4 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicate spLcific a ul ment I sl iected/serviced: Tank ID: N/A Tank ID: N/A In-Tank Gauging Probe. Model: NIA In-Tank Gauging Probe. Model: N/A Annular Space or Vault Sensor. Model: NIA Annular Space or Vault Sensor. Model: N/A Piping Sump/Trench Sensor(s). Model: NIA Piping Sump/Trench Sensor(s). Model: NIA Fill Sump Sensor(s). Model: NIA Fill Sump Sensor(s). Model: N/A Mechanical Line Leak Detector. Model: NIA Mechanical Line Leak Detector. Model: N/A Electronic Line Leak Detector. Model: N/A Electronic Line Leak Detector. Model: NIA Tank Overfill/High-Level Sensor. Model: NIA Tank Overfill/High-Level Sensor. Model: N/A Other s eci equipment and model in Section E on Pae 2). Others fy 2quipMent po and model in Section E on Page 2). Tank ID: N/A Tank ID: NIA In-Tank Gauging Probe. Model: N/A in-Tank Gauging Probe. Model: N/A Annular Space or Vault Sensor. Model: NIA Annular Space or Vault Sensor. Model: N/A Piping Sump/Trench Sensor(s). Model: NIA Piping Sump/Trench Sensor(s). Model: NIA Fill Sump Sensor(s). Model: NIA Fill Sump Sensor(s). Model: N/A Mechanical Line Leak Detector. Model: NIA Mechanical Line Leak Detector. Model: N/A Electronic Line Leak Detector. Model: NIA Electronic Line Leak Detector. Model: NIA Tank Overfill/High-Level Sensor. Model: N/A Tank Overfill/High-Level Sensor. Model: NIA Others ci ui ment tX122 and model in Section E on Pae 2). Others ci ui ent!yp2 and model in Section E on Pae 2). Dispenser ID: 23 Sat Dispenser ID: 24 Main Dispenser Containment Sensor(s). Model: 794380-208 . Dispenser Containment Sensor(s). Model: 794380.20a Shear Valve(s). ` Shear Valve(s). Dis enser Containment Floats and Chain(s). Disp2nser Containment Floats and Chain(s). Dispenser ID: 24 Sat Dispenser ID: 25 Main • Dispenser Containment Sensor(s). Model: ' Dispenser Containment Sensor(s). Model: 794380-208 x Shear Vatve(s). 9 Shear Valve(s). Dis enser Containment Floats and Chains. Dispenser Containment Floats and Chain(s). Dispenser ID: 25 Sat Dispenser ID: 26 Main x Dispenser Containment Sensor(s). Model: 794380-208 9 Dispenser Containment Sensor(s). Model: 794380.208 Shear Valve(s). . Shear Valve(s). Disp2nser Containment Float�sj and Chains 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): 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 / 14/ 2 0 1 4 Monitoring System Certification Page of 12107