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- Appendix VI JUN 12 Zia 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 UST systems within 30 days of test date. A. General Information Pilot-FI In J#618 N1501 Facility Name: y g Bldg. o.: Site Address: 1501 N Jack Tone Rd. City: Ripon Zip: 95366 Facility Contact Person: Manager Contact Phone No.:( 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: Vent Box Tank ID: Bio Shed ❑ In-Tank Gauging Probe. Model: N/A ❑ In-Tank Gauging Probe. Model: N/A ❑ Annular Space or Vault Sensor. Model: N/A ❑ Annular Space or Vault Sensor. Model: N/A C Piping Sump/Trench Sensor(s). Model: 794390-208/794380-304 )[] Piping Sump/Trench Sensor(s). Model: 794380-208/794380-304 ❑ Fill Sump Sensor(s). Model: N/A ❑ Fill Sump Sensor(s). Model: N/A ❑ Mechanical Line Leak Detector. Model: N/A ❑ Mechanical Line Leak Detector. Model: N/A ❑ Electronic Line Leak Detector. Model: N/A ❑ Electronic Line Leak Detector. Model: N/A ❑ Tank Overfill/High-Level Sensor. Model: N/A ❑ Tank Overfill/High-Level Sensor. Model: N/A ❑ Other(specify equipment t e and model in Section E on Pa e 2). ❑ Other(specify equipment t e and model in Section E on Page 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(sgecify a ui ment type and model in Section E on Pae 2). ❑ Other(s2ecify a ui ment type and model in Section E on Pae 2). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ is enser Containment Floats and Chains. ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dis enser Containment Floats and Chains. ❑ Dispenser Containment Floats and Chain(s). 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 ❑ 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 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): 91 System set-up 4:1 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