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E Appendix VI z. MONITORING SYSTEM CERTIFICATION For Use By A#Jurisdictions Within the State of California AuthorityCited: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 9 Bldg.No.: Site Address: 1501 N.Jack Tone Rd. City: Ripon, CA. Zip: 95366 Facility Contact Person: Manager Contact Phone No.: 2( 09 ) 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 Insl ected/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: ❑ 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: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment and model in Section E on PM 2). ❑ Other uipLnent b22 and model in Section E on P2. 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: ❑ Fill Sung Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Maki: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other Lsp29A 2guippent and model in Section E on Pae 2). ❑ Other Lsp2a 2guipaniDeeand model in Section E on Page 2). Dispenser ID: 29s Dia ID: 30M JU Dispenser Containment Sensor(s). Mail: 7994380-208 Ki Dispenser Containment Sensor(s). Model: 7943384-208 C Shear Valve(s). xj Shear Valve(s). ❑_Rd �nser Containment Floats and Chain(s). ❑ Di Containment Fbat s and Chains. Dispenser ID: 30s Dispenser ID: Ti Dispenser Containment Sensor(s). Madel: 794380-208 ❑ Dispenser Containment Sensor(s). Model: C Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ DiNner Containment Floats and Chain(s). Dispenser ID: Disperser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ D' neer Containment Floats and Chains ❑ Di Containment Float(s)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 - 1 certify that the equipment Identified in this document was Inspectediserviced in accordance with the manufacturers' guidelines. Attached to this Certification is information(e.g.man rs'checklists)necessary to verity that this Information Is correct and a Plot Pian showing the layout of monitoring equipment For any equipment capable of generating such reports,l have also attached a copy of the report;(cheek ad that apply): 91 System set-up x Alarm history report Technician Name(print): James Blaine Signature: Certification No.: V-R#-843163 / tCC#-8469775 License.N:.. 804431 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 12/07