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�it:UtivtL/I <br /> Appendix VI JUN 12 2015 <br /> -E , <br /> MONITORING SYSTEM CERTIFICATION NVIRONMENW. <br /> For Use By All Jurisdictions Within the State of California <br /> Authority Cited:Chapter 6.7, Health and Safety Code;Chapter 16,Division 3, Title 23, California Code of <br /> Regulations <br /> This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for <br /> each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system <br /> 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. <br /> A. General Information <br /> Facility Name: _ Pilot-Flying J#618 Bldg.No.:1501 <br /> Site Address: 1501 N Jack Tone Rd. City: Ripon Zip: 95366 <br /> Facility Contact Person: Manager Contact Phone No.:(209 599-4141 <br /> Make/Model of Monitoring System: TLS 350 Date of Testing/Servicing: 0 5 / 14/ 2 0 1 5 <br /> B. Inventory of Equipment Tested/Certified <br /> Check thea ro riate boxes to indicates ecific equipment ins l iected/serviced: <br /> Tank ID: Tank ID: <br /> 0 In-Tank Gauging Probe. Model: 0 In-Tank Gauging Probe. Model: <br /> 0 Annular Space or Vault Sensor. Model: 0 Annular Space or Vault Sensor. Model: <br /> 0 Piping Sump/Trench Sensor(s). Model: 0 Piping Sump/Trench Sensor(s). Model: <br /> 0 Fill Sump Sensor(s). Model: El Fill Sump Sensor(s). Model: <br /> El Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: <br /> 0 Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: <br /> 0 Tank Overfill/High-Level Sensor. Model: 0 Tank Overfill/High-Level Sensor. Model: <br /> 0 Other(specify equiement type and model in Section E on Pae 2). 0 Other(specify equipment type and model in Section E on Page 2). <br /> Tank ID: Tank ID: <br /> 0 In-Tank Gauging Probe. Model: 0 In-Tank Gauging Probe. Model: <br /> 0 Annular Space or Vault Sensor. Model: 0 Annular Space or Vault Sensor. Model: <br /> 0 Piping Sump/Trench Sensor(s). Model: 0 Piping Sump/Trench Sensor(s). Model: <br /> 0 Fill Sump Sensor(s). Model: 0 Fill Sump Sensor(s). Model: <br /> 0 Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: <br /> 0 Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: <br /> 0 Tank Overfill/High-Level Sensor. Model: 0 Tank Overfill/High-Level Sensor. Model: <br /> 0 Other(specify eguipment type and model in Section E on Page 2). ecifx equiement toe and model in Section E on Pae 2. <br /> Dispenser ID: 20S Dispenser ID: 21M <br /> )[I Dispenser Containment Sensor(s). Model: 794380-208 C Dispenser Containment Sensor(s). Model: 7943BO-208 <br /> JO Shear Valve(s). t Shear Valve(s). <br /> 0 Dispenser Containment Float(s)and 0 Dispenser Containment Float(s)and Chain(s). <br /> Dispenser ID: 21S Dispenser ID: 22M <br /> C Dispenser Containment Sensor(s). Model: 794380-208 C Dispenser Containment Sensor(s). Model: 794380-208 <br /> Ti Shear Valve(s). C Shear Valve(s). <br /> 0 Dispenser Containment Float(s)and Chain(s). 0 Dispenser Containment Floats)and Chain�s). <br /> Dispenser ID: 22S Dispenser ID: 23M <br /> • Dispenser Containment Sensor(s). Model: 794380-208 n Dispenser Containment Sensor(s). Model: 794380-208 <br /> • Shear Valve(s). C Shear Valve(s). <br /> ❑ iseenser Containment Float(s)and Chains 0 Diseenser Containment­ .1 1and Chains. <br /> *If the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility. <br /> C. Certification - I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' <br /> guidelines. Attached to this Certification is information(e.g.manufacturers'checklists)necessary to verify that this information is correct <br /> and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attached a <br /> copy of the report;(check all that apply): 91 System set-up C Alarm history report <br /> Technician Name(print): Issac Garcia Signature: <br /> Certification No.: B42806 License.No.: 804431 <br /> Testing Company Name: Jones Covey Group, Inc. Phone No.:(888 972-7581 <br /> Testing Company Address. 9595 Lucas Ranch Rd.#1 00 Rancho Cucamonga CA,91730 Date of Testing/Servicing:0 5 / 14/ 2 0 1 5 <br /> Monitoring System Certification Page of 12/07 <br />