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Appendix VI !UN 12 2015 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, a i pla, R 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 PIIOt-FI In 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.:(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 indicatespecific a ui ment insl iected/serviced: Tank ID: Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment t e and model in Section E on Pae 2). ❑ Other�specify equipment t e and model in Section E on Pae 2). Tank ID: Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment t e and model in Section E on Pae 2). ❑ Other(seecify equipment t e and model in Section E on Pae 21. Dispenser ID: 29S Dispenser ID: 30M • Dispenser Containment Sensor(s). Model: 794380-208 n Dispenser Containment Sensor(s). Model: 794380-208 • Shear Valve(s). rf7 Shear Valve(s). ❑ Dis enser Containment Floats and Chains. ❑ Disp2nser Containment Floats and Chain(s). Dispenser ID: 30S Dispenser ID: U Dispenser Containment Sensor(s). Model: 794380-208 ❑ Dispenser Containment Sensor(s). Model: U Shear Valve(s). ❑ Shear Valve(s). ❑ Dis enser Containment Floats and Chain(s). ❑ Dispenser Containment Float s and Chains. Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chains ❑ Dis enser 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): N System set-up in Alarm history report Technician Name(print): Issac Garcia Signature: Certification No.: 842806 License.No.: 804431 Testing Company Name: Jones Covey Group, Inc. Phone No.:(888 972-7581 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