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Appendix V:! " N", `' ?,017U{i+�'!;'. 5 P and i MONITORING SYSTEM CERTIFICATIONt� ti , 'i,ra I (y' 8 HEALTH For Use By All Jurisdictions Within the State of California ;fib i,9 Authority Cited:Chapter 6,7, east an Safety Cade;Chapter 16, Division 3, Title 23, Califa6rnla d� 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 Facility Name: Pilot Flying J 618 Bldg.No.: Site Address: 1501 N Jacktone Rd City: Ripon Zap: 95366 Facility Contact Person: Manager Contact Phone No.: Zo( 9 ) 589-4141 Make/Model of Monitoring System: TLS 350 Date of Testing/Servicing:0 5i 0 1! 0 1 7 B. Inventory of Equipment Tested/Certified Check the aro riate boxes to indicates ecific a ui ment in ected/serviced: Tank to: T5 91 12k Tank ID: T6 Auto dieaei 12k In-Tank Gauging Probe. Model: 847390.109 T In Tank Gauging Probe. Model: 847390-los Annular Space or Vault Sensor. Model: 7s438as03 Annular Space or Vault Sensor. Model: 79438)-303 Piping Sump/Trench Sensor(s). Model: 794380-218 Piping Sump!Trench Sensor(s), Model: 79380-208 Fill Sump Sensor(s). Model: N/A Fill Sump Sensor(s), Mechanical Line Leak Detector. Model: Vmi LD2000 Mechanical Line Leak Detector. Model: FXIVD Electronic Line Leak Detector. Model: N/A Electronic Line Leak Detector. Model: N/A Tank Overfill/High-Level Sensor. Model: oPW Flapper Tank Overfill/High-Level Sensor. Model: oPw Flapper Other s eci ui ment t sand model in Section E on Pae 2. Others c e ui ment a and model in Section E on Pa e 2. Tank ID; TanklD. In-Tank Gauging Probe. Model: in-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: = Annular Space or Vault Sensor. Model: u 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 s ecif a ui ment a and model in Section E on Pae 2)_ Others eci a ui ent a and model in Section E on Pa e 2. DlSer ID: 13 Dispenser ID: 14-15 Dispenser Containment Sensor(s). Model: 794380-208 'c-- Dispenser Containment Sensor(s). Madel: 794380-208 Shear Valve(s). Shear Fiss erValContainment � Dispenser Containment Floats and Chains. er Containment Floats and Ghain s). ID: 16 Dispenser ID: 19M ser Containment Sensor(s). Model: 794380-2)8 Dispenser Containment Sensor(s). Model: 79438)-za8 aive(s). Shear Valve(s). ser Containment Floats and Chains. Dis enser Containment Floats and Chains. ID: 19s Dispenser to:ser Containment Sensor(s). Model: 794380-208 Dispenser Containment Sensor(s). Model: 794380-208 alve{s). Shear Vatve(s). er Containment Floats and Chains Dis enser Containment Floats and Ghain s. *If the facility contains more tanks or dispensers,copy this farm. 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 shoving 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): jC System set-upAlar is re Technician Name(print): Daniel Marroquin Signature: Certification No.: 842821 License.No.: 8044 1 Testing Company Name. Jones Covey Group, Inc_ Phone No.: 88! ) 972-7581 Testing Company Address: 9595 Lucas Ranch Rd.#100 Rancho Cucamonga CA,91730 Date of Testing/Servicing:¢ 5 i 0 1/ 2 0 1 7 Monitoring System Certification Page of 12/07