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y aU Appendix VI ., . . MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority Cited.Chapter 6.7,Health and Safety Code;Chapter 16,Division 3, 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 Flying J#618 Facility Name: y g Bldg.No.: Site Address: 1501 N.Jack Tone Rd. City: Ripon, CA. Zip: 95366 Facility Contact Person: Manager Contact phone No.:( 9 1 599-4141 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 indicatespecific Nuipment In serviced: Tank ID: Tank ID: 0 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: 0 Tank Overfill/High-Level Sensor. Model: ❑ Other(specify® u' eM bT2 and model in Section E on Pae 2). ❑ Other u' ent bo and model in Section E on Eao L. Tank ID: Tank ID: ❑ In-Tarn Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: 0 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: 0 Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(§p22!!y 2guippent a and model in Section E on Page 2). ❑ Other u' ent bo and model in Section Eon Pae 2L Dispenser ID: 23S Dispenser ID: 24M vo Dispenser Containment Sensor(s). Model: 794380-208 KI Dispenser Containment Sensor(s). Model: 794380-208 3U Shear Valve(s). xrl Shear Valve(s). ❑ Dis nser Containment Floats and Chain(s). ❑ Dis nser Containment Floats and Chains. Dispenser ID: 24S Dispenser ID: 25M 'f7 Dispenser Containment Sensor(s). Model: 794388208 11�1 Dispenser Containment Sensor(s). Model: 794380-208 Shear Valve(s). xj Shear Valve(s). ❑ Dispenser Containment Floats and Chains. ❑ Dignnser Containment Floats and Chain(s). Dispenser ID: 25s Dispenser ID: 26m m£1 Dispenser Containment Sensor(s). Model: 794380-208 x3 Dispenser Containment Sensor(s). Model: 794380-208 C Shear Valve(s). 3U Shear Valve(s). ❑ Di§p2nser Containment Floats and Chains I ❑ Disp2Lm2r Containment Floats 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 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 Plot Plan showing the layout of monitoring equipment For any equipment capable of generating such reports,I have also attached a copy of the ;(check aff that appfy): C System set-up C Alarm history report Technician Name(print): James Blaine Signature: _ _ Certification No.: V-R#-843163 / ICC#-8469775 .ham„ $ 31 Testing Company Name: Jones Covey Group, Inc. Phi 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 12107