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� >, •�,� 'V `4� E f 9 dh Appendix i 2 2017 MONITORING SYSTEM CERTIFICATION HEALTH For Use By All Jurisdictions Within the State of California ;3; ENT Authority Cited.Chapter 6,7,Health and Safety Code;Chapter 16, Division 3, Title 23, Califor o f'°h..,�� 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 Flying J 618 Bldg.No.: Facility Name: Site Address: 1501 N Jacktone Rd City: Ripon Zip: 95366 Facility Contact Person: Manager Contact Phone No.: 20( s ) b'39 4141 MakeiModel of Monitoring System:TLS 350 Date of Testing/Servicing:0 5/� 2 0 1 7 S. Inventory of Equipment Tested/Certified Check the aEeroerlate boxes to indicatespecific ui ment in cted/serviced: Tank ID: Tank ID: E,, 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 sci a ui ent t e and model in Section E on Pa e 2. Other s ci e uiment on and model in Section EPae2. 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: Others cif a ui ment type and model in Section E on Pa e 2. Other(sRecijX.0 ui ment type and model in Section E on Pa e a-. Dispenser ID: los Dispenser ID: 21M Dispenser Containment Sensor(s). Model: 794380-208 r Dispenser VatContainment Sensor(s). Model: 794380-208 Shear Valve(s). Shear Dis enser Containment Float s)and Chains. Dis enser Containment Floats and Chains. Dispenser ID: 21S Dispenser ID: 22M Model: 794380-208 Dispenser Containment Sensor(s). Model: 794380-208 = Dispenser Containment Sensor(s), Shear Valve(s). Shear Valve(s). Dis enser Containment Floats and Chain(s). Dispenser Containment Float s)and Chains). Dispenser ID: 22s Dispenser ID: 23M Dispenser Containment Sensor(s). Model: 7943M208 Dispenser Containment Sensor(s). Model: 7943ao-208 Shear Valve(s). Shear Valve(s). Dispenser Containment Floats and Chains Dis enser Containment Floats and Chains. "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 verity that this information is correct and a Plot Pian showing the layout of monitoringS stemme t u For any �m history report of generating such reports,i have also attached a copy of the report;(check all that apply): Y p Technician Name(print), Daniel Marroquin Signature: Certification No.: 842621 License.No.: 80 31 88 Testing Company Name: Jones Covey Group, Inc. Phone No.:( 8 ) 972-7581 Testing Company Address: 9595 Lucas Ranch Rd.9100 Rancho Cucamonga CA,91730 Date of Testing/Servicing:0 5/O 1/ 2 0 1 7 Monitoring System Certification Page of 12/07