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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 LIST systems within 30 days of test date. A. General Information Pilot-Flying J#618 1501 Facility Name: y g Bldg.No.: Site Address: 1501 N Jack Tone Rd. City: Ripon Zip: 95366 Facility Contact Person: Manager Contact Phone No.: 20( 9 ) 599-4141 Make/Model of Monitoring System: TLS 350 Date of Testing/Servicing: 0 5 / 14/ 2 0 1 5 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific a ui ment insl iected/serviced: Tank ID: T1 Diesel 20K Tank ID: T2 Diesel 20K 43 In-Tank Gauging Probe. Model: 847390-109 M3 In-Tank Gauging Probe. Model: 847390-109 )❑ Annular Space or Vault Sensor. Model: 794380-303 93 Annular Space or Vault Sensor. Model: 794380-303 z❑ Piping Sump/Trench Sensor(s). Model: 794380-208 )G Piping Sump/Trench Sensor(s). Model: 794380-208 ❑ Fill Sump Sensor(s). Model: N/A ❑ Fill Sump Sensor(s). Model: N/A >£7 Mechanical Line Leak Detector. Model: Fx1VD A] Mechanical Line Leak Detector. Model: VMl LD2000 ❑ Electronic Line Leak Detector. Model: N/A ❑ Electronic Line Leak Detector. Model: N/A x❑ Tank Overfill/High-Level Sensor. Model: OPW Flapper x❑ Tank Overfill/High-Level Sensor. Model: DPW Flapper ❑ Other(specify equipment t e and model in Section E on Page 2). ❑ Other(specify a ui ment type and model in Section E on Pae 2). Tank ID: T3 Diesel 20K Tank ID: T4 8712K )C In-Tank Gauging Probe. Model: 847390-109 4] In-Tank Gauging Probe. Model: 847390-107 HCl Annular Space or Vault Sensor. Model: 794380-303 A] Annular Space or Vault Sensor. Model: 794380-303 ki Piping Sump/Trench Sensor(s). Model: 794380-208 >O Piping Sump/Trench Sensor(s). Model: 794380-208 ❑ Fill Sump Sensor(s). Model: N/A ❑ Fill Sump Sensor(s). Model: N/A 0 Mechanical Line Leak Detector. Model: VMl LD2000 C Mechanical Line Leak Detector. Model: STP MLD ❑ Electronic Line Leak Detector. Model: N/A ❑ Electronic Line Leak Detector. Model: N/A .,p Tank Overfill/High-Level Sensor. Model: OPW Flapper C Tank Overfill/High-Level Sensor. Model: OPW Flapper ❑ Other(specify a ui ment type and model in Section E on Pae 2). ❑ Other s ecif a ui ment t e and model in Section E on Pae 2). Dispenser ID: t-2 Dispenser ID: 3-4 n Dispenser Containment Sensor(s). Model: 794380-208 n Dispenser Containment Sensor(s). Model: 794380-208 �3 Shear Valve(s). C Shear Valve(s). ❑ Dispenser Containment Floats and Chains. ❑ Dis enser Containment Floats and Chains. Dispenser ID: 5-6 Dispenser ID: 7-8 U Dispenser Containment Sensor(s). Model: 794380-208 C Dispenser Containment Sensor(s). Model: 794380-208 J0 Shear Valve(s). U Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Disp2nser Containment Floats and Chain(s). Dispenser ID: 9-10 Dispenser ID: 11-12 U Dispenser Containment Sensor(s). Model: 794380-208 rt] Dispenser Containment Sensor(s). Model: 794380-208 C Shear Valve(s). )t] Shear Valve(s). ❑ Dispenser Containment Floats and Chains ❑ Dispenser Containment Floats and Chains. .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,1 have also attached a copy of the report;(check all that apply): ®System set-up 19 Alarm history report issac Garcia Technician Name(print): Signature: Certification No.: 842806 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: 0 5 / 14/ 2 0 1 5 Monitoring System Certification Page of 12/07