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L kb JL.1 Appendix V1 JUN 12 2015 MONITORING SYSTEM CERTIFICATION �' _NVIRONMENTAL I I- For Use By All Jurisdictions Within the State of California 2"7-�177M 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-FI Facility Name: _ ying J#618 1501 Bldg.No.: Site Address: 1501 N Jack Tone Rd. City: Ripon - Zip: 95366 Facility Contact Person: Manager Contact Phone No.:(209 599-4141 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 indicates ecific equipment ins l iectad/serviced: TankID: TankID: 0 In-Tank Gauging Probe. Model: 0 In-Tank Gauging Probe. Model: 0 Annular Space or Vault Sensor. Model: 0 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: 0 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 type and model in Section E on Pa 2). 0 Other�specify equipment t 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: 0 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: 0 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 type and model in Section E on Page 2). 0 Other(specify equiement t and model in Section E on Page 2) Dispenser ID: 23S Dispenser ID: 24M )U Dispenser Containment Sensor(s). Model: 794380-208 U Dispenser Containment Sensor(s). Model: 794380-208 )U Shear Valve(s). )EI Shear Valve(s). 0 Dispenser Containment Float(s)and Chain(s). 0 Diseenser Containment Float(s)and Chain(s). Dispenser ID: 24S Dispenser ID: 25M C Dispenser Containment Sensor(s). Model: 794380-208 U Dispenser Containment Sensor(s). Model: 794380-208 )(I Shear Valve(s). U Shear Valve(s). 0 Dispenser Containment Floats)and Chain�s). 0 Dispenser Containment Floats)and Chain(s). Dispenser ID::_5S Dispenser ID: 26M )(I Dispenser Containment Sensor(s). Model: 794380-208 )0 Dispenser Containment Sensor(s). Model: 794380-208 )a Shear Valve(s). 43 Shear Valve(s). 0 Dispenser Containment Float(s)and 2hains . 0 Dis[Lenser Containment Float(s)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): 93 System set-up C Alarm history report Technician Name(print): Issac Garcia Signature: Certification No.: 842806 License.No.: 804431 Testing Company Name: Jones Covey Group, Inc. . Phone No.: 888 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