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r � AppendIx Y 0 F: 2011 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions within the state of California m Authority Cited:chapter 6.7, Health and Safety ode,Chapter 16, Division , . I �. til i 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 ownerloperator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Infon-nation Facility Name: Pilot Flying J 618 Bldg.No.: Site Address: 1501 N Jacktone Rd City: Ripon ZIP: 95366 Facility Contact Person: Manager Contact Phone No.:(20_ 9 ) 599-4941 Make/Model of Monitoring System: TLS 350 Date of Testing/Servicing:0 !a 11 2 0 1 7 8. Inventory of Equipment Tested/Certified Check the agEroDriate boxes to indicates cific ui anent ins eted/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: Mechanical Sump Sen . Model: Mechanical Line Leak Detector. Model: Mechanical Linnee Leak Detector. Model: EElectronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model Tank Overfill!High-Level Sensor. Model: Others ci e ui ment a and model in Section E on Pae 2. Others ci a ui ent a and model in Section Eon 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 Sensoria}. Model: Piping Sump/Trench Sensor(s). Model: Model: Fill Sump Sensor(s). Model: Fill Sump p/Trench 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 eci equipment a and model in Section E on Pa e 2. Other s eci ui ment a and model in Section E on Pa e 2. Dispenser ID- 26s Dispenser ID: 27M Dispenser Containment Sensor(s). Model: 7M80-208 = Dispenser Containment Sensor(s). Model: 794380-208 Shear Valve(s). Shear Valve(s). Dis enser Containment Floats and Chains. Dis enser Containment Floats and Chains. Dispenser iD: 275 Dispenser ID: 28rn s Dispenser Containment Sensor(s). Model: 7�so-248 � Dispenser Containment Sensor(s). Model: 794380-toe Shear Valve(s). = Shear Vaive(s). Dis enser Containment Floats and Chains. = Dis enser Containment Floats and Chains. Dispenser ID: 289 Dispenser!D: 2sM Dispenser Containment Sensor(s). Model: 794390-204 Dispenser Containment Sensor(a). Model: 794380-208 Shear Vaive(s). Shear s). Dis enser Containment Floats and Chains r Dis usserer C Containment Floats and Chain(s). `If the taicContains 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 aAplY): V System set-up y Alarm h 9 tory report Technician Name(print): Daniel Marroquin Signature: Certification No.: 842821 License.No.: 804431 Testing Company Name: Jones Covey Group,Inc. Phone No.: 8S( 8 } 972-7581 Testing Company Address: 9595 Lucas Ranch Rd.#100 Rancho Cucamonga CA,91730 Date of Testing/Servicing:0 5/0 1 i 2 0 1 7 Monitoring System Certification Page of 12107