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AMR Appendix V1 JUN 12 2015 MONITORING SYSTEM CERTIFICATIONENVIRONMEN TA 4 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 Facility Name: _ Pilot-Flying J#618 Bldg.No.:1501 Site Address: 1501 N Jack Tone Rd. City: Ripon Zip: 95366 Facility Contact Person: Manager Contact Phone No.: 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 aeproeriate boxes to indicatjjg22�ffic equipment ins l ected/serviced: Tank ID: T5 91 12K Tank ID: T6 Auto Diesel 12K Xj In-Tank Gauging Probe. Model: 847390-109 10 In-Tank Gauging Probe. Model: 847390-109 )(I Annular Space or Vault Sensor. Model: 794380-303 X❑ Annular Space or Vault Sensor. Model: 794380-303 C Piping Sump/Trench Sensor(s). Model: 794380-208 X13 Piping Sump/Trench Sensor(s). Model: 794380-208 0 Fill Sump Sensor(s). Model: N/A — 0 Fill Sump Sensor(s). Model: N/A )CI Mechanical Line Leak Detector. Model: VMl LD2066 )0 Mechanical Line Leak Detector. Model: FX1VD 0 Electronic Line Leak Detector. Model: N/A 0 Electronic Line Leak Detector. Model: N/A A3 Tank Overfill/High-Level Sensor. Model: OPW Flapper )U Tank Overfill/High-Level Sensor. Model: OPW Flapper 0 Other�specify equipment type and model in Section E on Page 2). 0 Other�specify equipment type and model in Section E on Page 2). Tank ID: Tank ID: 0 In-Tank Gauging Probe., Model: 0 In-Tank Gauging Probe. Model: 0 Annular Space or Vault Sensor. Model: D Annular Space or Vault Sensor. Model: 0 Piping Sump/Trench Sensor(s). Model: 0 Piping Sump/Trench Sensor(s). Model: 0 Fill Sump Sensor(s). Model: 0 Fill Sump Sensor(s). Model: D Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: 0 Tank Overfill/High-Level Sensor. Model: 0 Tank Overfill/High-Level Sensor. Model: 0 Other(specify equipment t and model in Section E on 0 Other�specify equipment t and model in Section E on Page Dispenser ID: 13 Dispenser ID: 14-15 C Dispenser Containment Sensor(s). Model: 794380-208 �] Dispenser Containment Sensor(s). Model: 794380-208 n Shear Valve(s). 13 Shear Valve(s). 0 Mpenser Containment Floats)and Chain(s). 0 Dispenser Containment Float(s)and Chain(s). Dispenser ID: 16 Dispenser ID: 19M • Dispenser Containment Sensor(s). Model: 794380-208 C Dispenser Containment Sensor(s). Model: 794380-208 • Shear Valve(s). C Shear Valve(s). 0 Dispenser Containment Float(s)and 0 Dispenser Containment Float(s)and Chain�s). Dispenser ID: 19S Dispenser ID: 20M )EI Dispenser Containment Sensor(s). Model: 794380-208 91 Dispenser Containment Sensor(s). Model: 794380-208 )0 Shear Valve(s). C Shear Valve(s). 0 Dispenser Containment Floats j and Chains 0 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 verity 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): 91 System set-up Z Alarm history report -_T_11�_�_Z� -- Technician Name(print): Issac Garcia Signature:— Certification No.: 642806 License.No.: 804431 Testing Company Name: Jones Covey Group, Inc. Phone No.:(A�8 1 972-7581 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