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Appendix V1 MONITORING SYSTEM CERTIFICATION For Use By Aff Jurisdictions Within the State of California Authority Cited. Chapter 6.7,Health and Safety Code;Chapter 16,Division 3, T14.1,°Cai#dr!- nia, d,-df;"-, 111'1,1_1 1- Regulations 1 -', - 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 LIST systems within 30 days of test date. A. General Information Facility Name: _ Flying J#618 Bldg.No.: Site Address: 1501 N.Jack Tone Rd. City: Ripon, CA. Zip: 95366 Facility Contact Person: Manager Contact phone No.:(209 599-4141 Make/Model of Monitoring System: TLS 350 Date of Testing/Servicing:0 5 /0 3 2 0 1 7 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicate speolfic!9ulpLnent in ected/serviced: Tank ID: Tank ID: 0 In-Tank Gauging Probe. Model: 11 In-Tank Gauging Probe. Model: Ej Annular Space or Vault Sensor. Model: C1 Annular Space or Vault Sensor. Model: [I Piping Sump/Trench Sensor(s). Model: 0 Piping Sump/Trench Sensor(s). Model: [I Fill Sump Sensor(s). Model: 11 Fill Sump Sensor(s). Model: Ej Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: D Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: El Tank Overfill/High-Level Sensor. Model: D Tank Overfill/High-Level Sensor. Model: 0 Other(specify equipment t22 and model in Section E on P20 o Other uipMent and model in Section E on Pa E 2). Tank ID: Tank ID: Ei In-Tank Gauging Probe. Model: 0 In-Tank Gauging Probe. Model: 0 Annular Space or Vault Sensor. Model: D Annular Space or Vault Sensor. Model: Ei Piping Sump/Trench Sensor(s). Model: C1 Piping Sump/Trench Sensor(s). Model: El Fill Sump Sensor(s). Model: 0 Fill Sump Sensor(s). Model: El Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: D Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: o Tank Overfill/High-Level Sensor. Model: 11 Tank Overfill/High-Level Sensor. Model: 0 Others qguippent po and model in Section E on Page 2). D Other uip!pent to and model in Section E on Page 2). Dispenser ID: 20S Dispenser ID: 21M JU Dispenser Containment Sensor(s). Model: 794380-208 '1 Dispenser Containment Sensor(s). Model: 794380-208 C Shear Valve(s). 0❑ Shear Valve(s) Ei D!gLenser Containment Float(s)and Chaln(s). D Dispenser Containment Float(s)and Chain(s). Dispenser ID: 21S Dispenser ID: 22M C Dispenser Containment Sensor(s). Model: n4380-2N xi Dispenser Containment Sensor(s). Model: 794380-208 r Shear Valve(s). C Shear Valve(s). o Dispenser Containment Float(s)and Chain(s). 0 Dispenser Containment Float(s)and Chain(s). Dispenser ID: 22S Dispenser ID: 23M c Dispenser Containment Sensor(s). Model: 794384208 mi Dispenser Containment Sensor(s). Model: 794380-208 C Shear Valve(s). xi Shear Valve(s). D D!gnnser Containment Float(s)and Chains lo Dispenser Containment Float(s)and Chain(s). *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 aft that Apply). 91 System set-up C Alarm history report Technician Name(print): James Blaine Signature: .: 8044 Certification No.:V-R#-843163 / ICC#-8469775 Ljcsn�,2ZOM0, 31 Testing Company Name: Jones Covey Group, Inc. phone No.:L909 972-7581 Testing Company Address: 9595 Lucas Ranch Rd.#1 00 Rancho Cucamonga CA,91730 Date of Testing/Servicing:0 5 /03/ 2 0 1 7 Moriftoring System Certification Pap Of 12/07