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Appendix VI MONITORING SYSTEM CERTIFICATION For Use By Alf Jurisdictions Within the State of Calrfomia Authority Cited:Chapter 6.7,Health and Safety Code;Chapter 16,Division 3, Title 2 i&rJiWddd of L F°____ALTH Regulations h� 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 Flying J#618 Facility Name: Y 9 Bldg.No.: Site Address: 1501 N.Jack Tone Rd. City: Ripon, CA. Zp: 95366 Facility Contact Person: Manager Contact phone No.:( 9 ) 599-4141 Make/Model of Monitoring System: TLS 350 Date of Testing/Servicing:0 5 /03/ 2 0 1 7 B. Inventory of Equipment Tested/Certified Check the aperopriate boxes to indicates c ul ment In /serviced: Tank ID: T1 Diesel#2 20k Tank ID: T2 Diesel#2 20k 147 In-Tank Gauging Probe. Model: 847390-109 C In-Tank Gauging Probe. Model: 8473WI09 ra Annular Space or Vault Sensor. Model: 794380-303 m Annular Space or Vault Seng. Model: 794380-303 )c Piping Sump/Trench Sensor(s). Model: 794380-208 c Piping Sump/Trench Sensor(s). Model: 794380-208 ❑ Fill Sump Sensor(s). Model: NIA ❑ Fill Sump Sensor(s). Model: N/A )C Mechanical Line Leak Detector. Model: FX1VD C Mechanical Line Leak Detector. Model: VMI LD200o ❑ Electronic Line Leak Detector. Model: NIA ❑ Electronic Line Leak Detector. Model: NIA rc Tank Overfill/High-Level Sensor. Model: DPW Flapper )CI Tank Overfill/High-Level Seng. Model: DPW Flapper ❑ Other(specify equIpTent tT2 and model in Section E on PM 2). ❑ Others ci ui ent typq and model in Section E on Pae 2). Tank ID:T3 Diesel#2 20k Tank ID: T4 8712k r® In-Tarn Gauging Probe. Model: 847390-109 w] In-Tank Gauging Probe. Model: 847390-107 >a Annular Space or Vault Sensor. Model: 794380-303 C Annular Space or Vault Sensor. Model: 794380-303 &U Piping Sump/Trench Sensor(s). Model: 794380-208 ap Piping Sump/Trench Sensor(s). Model 794380-208 ❑ Fill Sump Sensor(s). Model: NIA 11Fill Sump Sensor(s). Model: NIA 10 Mechanical Line Leak Detector. Model: VMI LD2000 )C Mechanical Line Leak Detector. Model: STP-MLD ❑ Electronic Line Leak Detector. Model: NIA ❑ Electronic Line Leak Detector. Model: NIA rp Tank Overfill/High-Level Sensor. Model: DPW Flapper x7 Tank Overfill/High-Level Sensor. Model: DPW Flapper ❑ Other ent tM and model in Section E on Page 2). ❑ Others i 2quipMent and model in Section E on Pa 2). Dispenser ID: 1-2 Dispenser ID: 34 3f] Dispenser Containment Sensor(s). Model: 79438x208 Dispenser Containment Sensor(s). Model: 794380-208 1f7 Shear Valve(s). 1h Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ DigNmer Containment Floats and Chain(s). Dispenser ID: 5.8 Dispenser 10: 7.8 r❑ Dispenser Containment Sensor(s). Mil: 79438x208 xi Dispenser Containment Sensor(s). Model: 794380-208 30 Shear Valve(s). X] Shear Valve(s). ❑ ispenm Containment Floats and Chain s. ❑ Dispenser Containment Float s and Chain s. Dispenser ID: 910 Dispenser ID: 11-12 mfi Dispenser Containment Sensor(s). Model: 794380-208 x� Dispenser Containment Sensor(s). Model: 794380-208 Shear Valve(s). 91 Shear Valve(s). ❑ gisp2nser Containment Floatsand Chain s ❑ Dispenser Containment Floats and Chain(s). 'If the facility contains more tanks or dispensers,copy this form. Include information for every tactic and dispenser at the facility. C. Certification - I certify that the equipment Identified In this document was ins 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 Piot 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 yr 9 System set-up ®Alarm history report Technician Name(print): James Blaine Signature: Certification No.: V R#-843163 / tCC#-b469775 License. ,!,.:�O44,1 Testing Company Name: Jones Covey Group, Inc. pie No.. 9( 09 ) 972-7581 Testing Company Address: 9595 Lucas Ranch Rd.#100 Rancho Cucamonga CA,91730 Date of Testing/Servicing:0 5 /03/ 2 0 1 7 Monitoring System Certification page of 12/07