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7 Appendix V1 R - 2 2 C1 I MONITORING SYSTEM CERTIFICATION For use By All Jurisdictions Within the State of California Authority Cited hapten .7,Health and fey Code;Chapter 1 , ivision , Tit/ I o. i lik, t I L. LT T 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 Jacldone Rd City: Ripon Zip: 95366 Manager Contact Phone No.: 20( 9 1 599A141 Facility Contact Person: g Make/Model of Monitoring System: TLS 350 Date of Testing/Servicing:0 5!0 1/ 2 0 1 7 B. Inventory of Equipment Tested/Certified Check the aperoEriate boxes to indicates ecific ui anent Ins ected/serviced: 77 Tank 10: Probe- Tank In Tank Gauging Probe. Model: !n-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: Piping Sump!Trench Sensar(s). Model: Piping Sump/Trench Sensor(s). Model: Fill Sump Sensors}. 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: kTank nk Overfill/High-Level Sensor. Model: Tank Overfill 0 High-Level Sensor. Model: hers i a u! ment a and model in Section E on Pa e 2. Other s eci a ui ent a and model in Section a on Pa e 2. ID: Tank 101: -Tank Gauging Probe. Model: In-Tank Gauging Probe. Madel: Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model. Piping Sump r Trench Sensor(s). Model: = Piping Sump/Trench Sensor(s). Model: Pili Sump Sensor(s). Model Fill Sump Sensor(s). Model: Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill i High Level Sensor. Model: Tank Overfill/High-Level Sensor. Model: Others ci a ui ment a and mode!in Section E on Pa 2. Others ci ui went and model in Section E an D ispenserID: 29s Dispenser ID: 3D"a a 794380-208 Dispenser Containment Sensors}. Model: � �-�$ Dispenser Containment Sensor(s). Model: P r Valve(s). Shear Valve(s). nser Containment Flaat s and Chains. Dis enser Containment Float s)and Chain s'. er ID: 30S DOSpenser I€}:nser Containment Sensor(s)_ Model: 7sa380-208Dispenser Corrtainment Sensors). Model: r Valve(s). Shear Vafve(s). nser Containment Floats and Chain(s). � Dis enser Containment Float(s)and Chain(s). erID: DispenserID: enser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: r Valve(s). Shear Valve(s).nser 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 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): ;f,System set-up N,elarm history report Technician Name(print): Daniel Marroquin Signature: Certification No.: 842621 License.No.: 04431 : Jones Covey Group, Inc, Phone No.: $( )M 972-7581 Testing Company Name Testing Company Address: 9595 Lucas Ranch Rd_#100 Rancho Cucamonga CA,91730 Data of Testing/Servicing:0 5/0 1/ 2 0 1 7 Monitoring System certification Page of 12107