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Appendix VI JUN 0 3 2016 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, Title 23, California Code of 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 1501 Facility Name: y g Bldg. No.: Site Address: 1501 N Jacktone Rd. Facility Contact Person: Manager Make/Model of Monitoring System: TLS 350 B. Inventory of Equipment Tested/Certified City: Ripon Contact Phone No.: ( 209 Zip: 95366 599-4141 Date of Testing/Servicing: 0 5/ 04 / 2 0 1 6 -it the tacuity contains more tanKs or aispensers, copy tis Corm. mcwae mtormauon Tor every tanK ana aispenser at me Tacwty. 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): Id System set-up ® Alarm history report Issac Garcia Technician Name (print): Signature: Certification No.: 642806 License. No.: 804431 Testing Company Name: Jones Covey Group, Inc. Phone No.: 88( 8 ) 972-7581 Testing Company Address: 9595 Lucas Ranch Rd.#100 Rancho Cucamonga CA,91730 Date of Testing/Servicing: 0 5 / 04 / 2 0 1 6 Monitoring System Certification Page of 12107 cnecK ine appro nate Doxes to intlicate s eci is si ieciecii/servicea: 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 t e and model in Section E on Pae 2). cify equipment t e and model in Section E on Pae 2). 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 t e and model in Section E on Pae 2). ❑ Other(specify equipment t e and model in Section E on Pae 2 . Dispenser ID: 26S Dispenser ID: 27M T❑ Dispenser Containment Sensor(s). Model: 794380-208 TE1 Dispenser Containment Sensor(s). Model: 794380-208 U Shear Valve(s). C Shear Valve(s). ❑ Dis enser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: 27S Dispenser ID: 28M TE] Dispenser Containment Sensor(s). Model: 794380-208 £i Dispenser Containment Sensor(s). Model: 794380-208 U Shear Valve(s). JO Shear Valve(s). ❑ _Dispenser Containment Floats and Chains . ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: 28S Dispenser ID: 29M t❑ Dispenser Containment Sensor(s). Model: 794380-208 U Dispenser Containment Sensor(s). Model: 794380-208 U Shear Valve(s). )0 Shear Valve(s). ❑ Dispenser Containment Floats and Chains ❑ Dis enser Containment Floats and Chain(s). -it the tacuity contains more tanKs or aispensers, copy tis Corm. mcwae mtormauon Tor every tanK ana aispenser at me Tacwty. 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): Id System set-up ® Alarm history report Issac Garcia Technician Name (print): Signature: Certification No.: 642806 License. No.: 804431 Testing Company Name: Jones Covey Group, Inc. Phone No.: 88( 8 ) 972-7581 Testing Company Address: 9595 Lucas Ranch Rd.#100 Rancho Cucamonga CA,91730 Date of Testing/Servicing: 0 5 / 04 / 2 0 1 6 Monitoring System Certification Page of 12107